Public health working with the voluntary, community and social enterprise sector: new opportunities and sustainable change

Case studies Cover image: Making soup with Durham Wellbeing for Life Service

Acknowledgements We are very grateful to the local authorities and voluntary, community and social enterprise organisations featured in this report.

Disclaimer The views expressed in the publication are those of the contributing organisations and do not necessarily reflect the views of the Local Government Association.

## Contents

| Section | Page | |------------------------------------------------------------------------|------| | Foreword | 4 | | Summary of main themes | 6 | | Introduction | 8 | | Partnerships and engagement | 10 | | Improving the lives of older people in Brighton & Hove | 13 | | London Councils’ joint work: declaration on sugar reduction and healthier food | 15 | | RoSPA – preventing accidents, saving lives and reducing injuries | 15 | | Commissioning and new delivery models | 17 | | A strategic approach to working with the VCSE in Leeds | 19 | | Strategic partnerships in Tower Hamlets | 21 | | Supporting a sustainable future | 24 | | Healthy Homes and Warm and Well in Norfolk | 28 | | Social investment to tackle loneliness in Worcestershire | 30 | | Integrating services | 32 | | One You Cheshire East – integrated lifestyle and wellness support service | 35 | | Integrated health and wellbeing service with an academic evaluation in County Durham | 36 | | Living Well with Sefton’s integrated wellness service | 38 | | Community-centred approaches | 41 | | Wakefield – VCSE sector is key partner in integration pioneer and care model vanguards | 44 | | Holiday Kitchen collaboration for disadvantaged children in Birmingham | 46 | | Support for marginalised people in Blackpool | 48 | | Public health in partnership with the VCSE sector: suggestions for good practice | 49 | | References and resources | 52 | Forewords

Local Government Association

I was delighted to see the excellent examples in this report which show how public health and the voluntary, community and social enterprise sector (VCSE) are working together to make a real difference to people’s health and wellbeing. Local government has always been a close partner to the VCSE sector, and now, with public health colleagues, we are able go further and faster in harnessing the skills, enthusiasm and expertise of VCSE organisations and volunteers.

The increasing emphasis on prevention and integration has brought new opportunities for the sector, which has stepped up to meet the challenge. New investment has been particularly positive at a time when statutory agencies as a whole were often looking to reduce funding. Now, at a time of severely constrained resources for both local government and the NHS, it is even more important that we work together as equal partners to mobilise all our assets to tackle poor health and health inequalities.

To achieve this, it is important to establish a culture of cooperation and collaboration in which the VCSE sector contributes to the strategic vision for council areas and regions, and in which it has the security to deliver high quality, responsive activity to help individuals and communities to take steps to improve their health and wellbeing. Public health has an important role in helping to establish this culture.

This report builds on the work of the case studies and draws on recent guidance on commissioning, engagement and community action to provide proposals for good practice. I hope that the report will help local authorities, the NHS and the VCSE sector to work ever more closely together to address the social determinants of health and improve the health of individuals and the communities in which they live.

Councillor Izzi Seccombe Chair, LGA Community Wellbeing Board Volunteering Matters

Volunteering Matters is pleased to have been asked by the LGA to assist with the production of this report, in our role as a member of the Health and Care Voluntary Sector Strategic Partnership Programme.

The report provides a timely and compelling reminder that a sustainable and diverse voluntary, community and social enterprise sector is essential if local authorities are able to realise their potential to help improve the health and wellbeing of their local communities. Meaningful partnerships between VCSE organisations and local government are critical if we are to respond effectively to the major public health issues of our time, such as health inequalities, obesity, and the mental health of children and young people.

It is important that both the VCSE sector and councils work together to promote better understanding of the important role of the sector in helping to identify, give voice and respond to public health needs in local communities as an essential element of good planning and commissioning. VCSE organisations bring their own resources to local partnerships and are keen to share the work involved in supporting the creation of healthier communities.

This report provides excellent examples of how some areas are already achieving this. For example, it shows how commissioning in some councils is shifting from incentivising competition to encouraging collaboration, thereby enabling the VCSE sector to make best use of its capacity to work with partners to design and deliver local solutions.

However, across the country much more needs to be done. This report and the latest LGA Care Act stocktake describe how there is concern about the sustainability of the local voluntary, community and social enterprise sector. Addressing these concerns is a political, social and economic imperative for both national and local government.

Oonagh Aitken, Chief Executive, Volunteering Matters

1 LGA (June 2016), Care Act Stocktake 6 http://www.local.gov.uk/care-support-reform/-/journal_content/56/10180/6341378/ARTICLE Summary of main themes

The case studies in this report show great mutual regard and understanding between public health and the VCSE sector – a relationships of equals. To achieve this across the country, more work is needed for public health to understand the positive contribution that VCSE organisations bring to health and wellbeing. The VCSE sector may also benefit from a better understanding of public health, and how local government operates at a time of significant challenge.

There is much that public health can do to work with the VCSE sector to support their role in promoting health and wellbeing, including making sure that they are well engaged in joint strategic needs assessments (JSNAs) and health and wellbeing boards (HWBs), updating the local Compact if needed, and encouraging the implementation of the Social Value Act.

As well as public health, other council departments and clinical commissioning groups (CCGs) also engage with, and commission, the VCSE sector. Joining up this work will bring economies of scale and will also avoid risks, such as destabilising VCSE organisations through untimely decommissioning.

VCSE infrastructure organisations, which provide overall coordination, championing training and commissioning support, make a huge contribution to positive working relationships and ultimately to health and wellbeing outcomes, provided they are focused on the needs of their members, have a ‘can-do’ approach and look outwards to create partnerships. In some areas, these are being squeezed through financial cuts.

Competitive tendering can bring important benefits of quality and value for money if it is applied effectively. However, procurement should be focused on outcomes, not process. It is also important to establish a culture of collaboration and cooperation so VCSE organisations and public health can work together to make improvements and find solutions. The case studies demonstrate what a collaborative approach can achieve.

The transfer of public health brought a time of expansion to the VCSE sector, with new contracts and new delivery models, often aimed at providing integrated services. Many new models are based on a lead provider responsible for service delivery across multiple providers, often from different sectors. Any new and untried arrangements require careful monitoring and support from public health.

The current climate of reduced resources is causing concern that some VCSE organisations, particularly small ones, may become unsustainable. Grass-roots community organisations are often very important from a public health perspective because of their links with people facing health inequalities. Some public health teams are working with council colleagues, CCGs and the local VCSE sector to improve sustainability, through measures such as market development and improving service evaluation.

As well as an overall shift to integrating public health services, such as sexual health, several of the case studies were implementing ambitious integrated health and wellbeing services. A range of models are being used, often putting different emphasis on the extent to which services focus on behaviour change or on the social determinants of health. Good practice emerging from front-runners, such as the importance of appointing a coordinator, is described in this report. Nationally, information to support integrating health and wellbeing services is at an early stage of development.

Several of the case studies were developing community-centred approaches, using different community development models, which are described in this report. Nationally, there is a significant body of information about community-centred approaches, and PHE is active in supporting developments in this area. Introduction

Both national and local government view the voluntary, community and social enterprise sector (VCSE) as a vital partner in putting prevention at the heart of health and care services, and supporting local communities to take a greater role in promoting health and wellbeing. Particularly at a time of decreasing resources, it is seen as essential that the skills and capacities of the sector are recognised and supported. The key message in this report is that public health has a central role in delivering this.

The transfer of public health to local authorities has brought about significant change in VCSE involvement in public health services. Across the country there has been a general increase in the VCSE contribution to public health, but this varies considerably from area to area – from those where the VCSE sector is an essential partner in developing the future of health and wellbeing interventions, to others where strategic engagement and opportunities to provide services are more limited.

This report considers some of the themes emerging from the first four years of public health in local authorities and makes a number of suggestions about good practice. It includes case studies which were submitted by directors of public health and regional PHE (PHE) offices, and through VCSE networks via the national volunteering and social action charity, Volunteering Matters, (formerly Community Service Volunteers – CSV). These show many ways in which public health is working with the VCSE in councils across England. So far as possible they include information from the perspective of both public health and the VCSE sector.

Themes and proposals for good practice come from these case study examples, and from examples in some other LGA documents – the Public Health Annual Report 2017(^2), and Working with faith groups(^3) – around 30 case study areas in total. Work on case studies involved discussions with over 50 representatives of public health and VCSE organisations. The report cannot be regarded as a formal analysis of the current state of the relationship between the VCSE sector and public health, but the consistency of messages from different areas suggests that they have a general relevance. One proviso is that the case studies have been submitted as examples of good practice, and are therefore more likely to describe positive relationships. To address the balance, the document also draws on other research, including the recent review of partnerships and investment in the voluntary, community and social enterprise sector, referred to as ‘the National VCSE review’.(^4)

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(^2) LGA (March 2017), Public health transformation four years on: maximising the use of limited resources. http://www.local.gov.uk

(^3) LGA (February 2017), Working with faith groups to promote health and wellbeing http://www.local.gov.uk/web/guest/publications/-/journal_content/56/10180/8220302/PUBLICATION

(^4) DH, PHE, NHS England (2016), Review of partnerships and investment in voluntary community and social enterprise organisations in the health and care sector – final report 2016 (‘The National VCSE Review’) https://VCSEreview.org.uk/ The main themes identified from the case studies form the subject of a section in this report. They are:

- partnerships and engagement
- commissioning and new delivery models
- supporting a sustainable future
- integrating services
- community-centred approaches.

Each of these is supplemented with information from national guidance to provide a full picture of good practice. Partnerships and engagement

A marked feature of the case studies in this report were the close, respectful and supportive working relationships between public health and the VCSE sector. There was a great sense of people working together as one team. They expressed mutual regard and understanding of each other’s roles, responsibilities and pressures. They also gave the same messages about what they were trying to achieve together and frequently praised the other for their contribution.

These positive partnerships were seen both at a senior leadership and strategic level, and also in specific projects where public health staff and VCSE organisations had been working together closely and had developed considerable trust and respect. While things were not perfect, they had the basis to work through problems together. Perhaps the fundamental element of these relationships was that they were partnerships of equals in which both had complementary roles.

However, across the country, although councils have reasonably good working relationships with the VCSE sector, for some these may not be as productive as they could be.

There may be many different reasons for this: belief that the public sector is the best place for the bulk of service delivery, or that the VCSE sector drives down workers’ terms and conditions; concerns that VCSE organisations may be less professional than the statutory sector; procedural approaches to procurement that tend to keep providers at arms-length. But perhaps the most common reason is a lack of familiarity with, and understanding of, the VCSE sector. It is possible to work in public health and other council departments, and have very limited dealings with the sector. Similarly, VCSE organisations may have little appreciation of how councils work and the pressures facing them. It is telling that in many of the case studies people pointed out that service coordinators and other key individuals had worked in both the statutory and the VCSE sectors, and therefore had an understanding of both.

Better understanding of the benefits of working with the VCSE sector

One way of improving understanding is for public health and the wider council to have a clear awareness of the extensive contribution that VCSE organisations can bring to health and wellbeing development and delivery. The VCSE sector is not a homogeneous group, but includes a range of attributes, capacities and skills. This extends from recognised national experts in a specialist area, to large organisations operating nationally and regionally, to medium-size charities with a strong local presence, to small, volunteer-led community organisations.

VCSE organisations are acknowledged as having distinct features which enable it to make contributions to health and wellbeing. The following attributes can be found in case studies throughout this report. They are also reflected in the ‘National VCSE Review’ and in a recent report commissioned by the Richmond Group of Charities demonstrating the expertise and experience of the voluntary and community sector.5

5 NPC (2016), Untapped potential: bringing the voluntary sector’s strengths to health and care transformation https://richmondgroupofcharities.org.uk/sites/default/files/aw_ncp_report\_-_untapped_potential_-\_single_pages.pdf • skill in working with communities and people facing health inequalities in deprived areas • closer to communities and user groups, so can reflect their views into strategic planning • sometimes more likely to have the trust of communities and individuals than statutory organisations • a commitment to helping marginalised groups over the longer term when public sector help may be time limited • responsive, flexible, innovative and more able to take risks • highly professional and skilled • specialist expertise in supporting a care group or addressing an issue • can keep costs down, so good value • potential to lever additional resources • skilled in attracting, training, deploying and keeping volunteers.

In some areas, public health is taking the opportunity to develop mutual understanding between public health and VCSE organisations, particularly helping the sectors to reflect on and understand their current pressures and priorities as a basis for future joint working.

In Wakefield, one of the gaps identified in the training needs of the VCSE sector was leadership, to enable people to progress in their careers and to bring leadership skills to the sector as a whole. At the same time, it was recognised that there was limited understanding across the council about how the sector operated and what it could achieve. A joint leadership programme in which VCSE and council managers train together has been established. VCSE participants have a mentor who is a senior leader in the statutory sector – including NHS trust and CCG chief executives and council directors – and participants from the statutory sector are mentored by VCSE chief executives. The course will allow current and future leaders to network and will raise the profile of the VCSE sector.

In Tower Hamlets, a public health specialist registrar (trainee consultant) was placed within two local organisations. The aims were to increase the registrar’s understanding of the VCSE sector and its contribution to health and wellbeing, and to work with local organisations to increase their understanding of the statutory sector, national policy changes and local population health priorities. This placement was carried out with partners in the Tower Hamlets CVS health and wellbeing forum.

**Public health and council relationships with the VCSE**

When public health operated in the NHS, it often took the lead in relationships with the VCSE sector. The transfer meant that public health joined councils which were also likely to have strong and extensive connections with the sector. How these two sets of relationships have come together, four years since transfer, has taken different forms. In some areas, public health has become the recognised leader for developing VCSE relationships across health and care, perhaps through a leadership role for supporting the health and wellbeing board (HWB). In others, adult social care or a central department retains a lead role, or different departments maintain their own, sometimes separate, lines of communication. The extent to which public health is involved in health and care commissioning also varies; many areas provide intelligence and data, a very few have a lead over wider health and care commissioning, and most are focused solely on public health aspects.

It is fair to say that the more that different parts of the council join up their work with the VCSE sector into a coherent and consistent approach, the better it will be for all concerned. For instance, there are examples where one part of the council decommissioned a VCSE organisation while another started to fund a similar service, but with no discussion taking place. Keeping the Compact live

The Compact is a voluntary agreement that aims to foster strong, effective partnerships between public bodies and voluntary organisations. The Compact is a resilient national policy that has remained in place, with some updating, since it was established in 1998.

As well as the national compact covering central government, nearly all local authority areas have their own locally designed compact which cover partnerships between the voluntary and community sector and councils, health commissioners, the police and fire services and others. Compact principles include:

- develop a framework for measuring social value in commissioning
- support innovative examples of early intervention and join up local services
- develop lasting partnerships between voluntary organisations and new commissioning bodies such as CCGs, HWBs, and Police and Crime Commissioners
- standardise commissioning practices and better support the involvement of voluntary sector providers.

Compacts tend to be established with enthusiasm, but are in danger of becoming a document on a shelf. One way of developing a consistent approach to working with the VCSE sector across a council is to revisit the Compact and make sure that all relevant staff, in the council, VCSE sector and the NHS have a good understanding of how it relates to their work, and to the many challenges facing local areas, such as reduced resources, devolution and sustainability and transformation plans (STPs).

Tower Hamlets is working with the VCSE sector to renew their compact in order to better reflect new ways of working together and shared aspirations and commitments as part of the delivery of a new local VCSE strategy.

A strong infrastructure organisation for strategic engagement

In several of the case studies in this report, VCSE infrastructure organisations, which provide overall coordination, championing, training and commissioning support for the sector, were seen as central to the VCSE relationship with public health and had contributed massively to an extended role in service delivery. In some areas, the VCSE sector also had a worker responsible for developing strategic relationships in health, care and wellbeing, and this was seen as a very helpful role.

Nova, Wakefield’s voluntary and community infrastructure agency, employs a health and social care advisor who works to ensure that the sector’s views are included in strategic planning and service delivery.

Tower Hamlets CVS employs a health lead, supported through CCG funding, who acts as a link and represents the sector on the HWB and other key strategic groups and to increase the understanding of the sector within statutory organisations.

Unfortunately, sometimes infrastructure organisations are under pressure, with their role threatened because they are not seen as providing direct services. The ‘National VCSE Review’ found that overall funding for infrastructure charities fell by a third between 2008/09 and 2013/14.

VCSE involvement in strategic planning

Well-run local infrastructure organisations are important for enabling the VCSE sector to contribute to strategic engagement through the HWB, JSNAs and key local strategies. In the ‘National VCSE Review’ some respondents felt that the sector was insufficiently involved in strategic planning, with particular concerns that they were not formally involved, and that decisions were made outside meetings when they were not present. While some were happy that they received feedback from their representatives, many did not know who their representative was.

A member survey by National Association for Voluntary and Community Action, the national infrastructure organisation, found that 86 per

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6 http://www.compactvoice.org.uk/ cent of HWBs had voluntary and community sector representation; on a more positive note, relationships with local health systems had improved on the previous year and only a ‘small minority’ of areas had ‘poor or non-existent’ relationships.7

With the shift towards working across larger geographical footprints through STPs and devolution, coordination for the VCSE sector will take on even greater importance, if their voice is to be heard at the increasingly crowded strategic planning table. It is important that public health is confident that the local VCSE sector is fully engaged in strategic planning, and that those not directly involved in meetings receive feedback and can also feed in. Some areas have dedicated strategic health and wellbeing forums so that the widest possible number of groups can be involved. The LGA has produced several recent guides providing information, guidance and good practice on engaging with the voluntary and community sectors.8,9

Improving the lives of older people in Brighton & Hove

Older volunteers combatting social isolation

LifeLines is a volunteer-led project for people aged 50 and over, based on the concept of recruiting, training and supporting older volunteers to set up activities that they are interested in, and which will be of interest to others. A huge range of activities has been delivered over the years, include cookery, art, tai chi, meditation, a computer club and learning a musical instrument. Many groups take place in the community space of an extra-care housing scheme, which has a coffee bar, and is accessible to members of the public as well as people from the scheme.

LifeLines was set up in 2007 and is part funded by Brighton & Hove City Council and the National Lottery. It is run by Volunteering Matters, the national charity which operates a wide range of volunteering and social action programmes across the country.

LifeLines specialises in the training and support of volunteers; for example, all are offered Royal Society of Public Health courses in health awareness. The support provided means that the project has many dedicated volunteers, some associated with the project from the start.

LifeLines is regularly evaluated. During the last three years, it has recruited 149 older volunteers, 371 older people have participated in volunteer-led activities, and 133 have benefitted from one to one volunteer support. Evaluations demonstrate significant health benefits for both volunteers and participants. For example, around 78 per cent of participants and 71 per cent of volunteers said they felt less isolated, and similar percentages reported increased self-confidence. Recommendations from evaluations, such as developing new activities for men, are incorporated into the programme wherever possible. The PrimeTime project replicates the LifeLines model, but with men aged 50 plus, and provides a database of other organisations providing relevant activities and information.

7 NAVCA (2016), Health and local infrastructure https://www.navca.org.uk/resources/134-health-and-local-infrastructure 8 LGA (2016 web), Community Action (web-based tools, resources and case studies) http://www.local.gov.uk/community-action 9 LGA (2016), Health in all policies: a manual for local government http://www.local.gov.uk/documents/10180/7632544/1.4+Health+in+ALL+polices_WEB.PDF/b21cf56f-403e-45c4-8a29-2c96df48acdb Commissioners and providers co-producing solutions Brighton & Hove Public Health are working with the wider council to create an environment of engagement and co-production with the VCSE sector, which is seen as a vital partner in improving health and wellbeing across the city.

One key way of doing this is through Citywide Connect – a network which runs regular events to bring together staff from the council, the NHS, and VCSE and independent providers of services for older people. Citywide Connect is coordinated by the charity Possibility People. The aim is to identify ways of working more effectively together at a time of reducing resources and growing demand. Citywide Connect meets twice a year in three ‘locality hubs’ covering different geographical areas of the city. Innovative ideas and solutions are also identified both within the events and outside, through social media. Hundreds of pledges and actions have been made since the programme started in 2014, in topics such as tackling social isolation, improving cross-organisation referrals, and falls prevention. An independent evaluation of the first two-years found that it had contributed many improvements:

- Ninety-one per cent of participants said Citywide Connect provided an effective forum for creating trusting relationships and a similar number attended to build new connections or explore collaboration opportunities.
- A theme through the evaluation was that it was changing cultures so that organisations were more willing to work together, share, learn and breakdown barriers. It was valued by all, but private sector providers were particularly pleased to be involved.
- Gaps identified by the programme have been filled, eg a new dementia café set up by a private sector organisation and a volunteer at no cost to the public sector.
- Individual workers have changed their practice and that of their organisation – for instance, putting a greater focus on combatting loneliness.
- The police, VCSE organisations and a council team came together to run a ‘Thinking of you at Christmas’ public health campaign.
- Connect and Share was set up as a community marketplace where members can make best use of their assets.
- A common assessment form and referral pathways have been devised.
- Cross sector networks have been established, including an older men’s network.

While it is not possible to directly attribute savings to the work of the programme, a very approximate estimate, based on a number of variables such as reduced use of health and social care, suggests potential savings in the region of £12 million a year.

Learning and messages From a VCSE perspective, the approach taken by public health to encourage partnerships and collaboration, rather than competition, in the sector is very welcome. It is also positive that public health take a close interest in how projects are performing, and support their work, rather than just focusing on contract monitoring.

Contact Alan Marchbank, Project Manager, Volunteering Matters Email: alan.marchbank@volunteerngmatters.org.uk

Annie Alexander, Public Health Programme Manager, Brighton & Hove City Council Email: annie.alexander@brighton-hove.gov.uk

Further information Lifelines http://lifelinesbrightonhove.org.uk/

Independent evaluation of Citywide Connect http://possabilitypeople.org.uk/wp-content/uploads/2016/11/Improving-lives-saving-money.pdf London Boroughs’ joint work: local government declaration on sugar reduction and healthier food to London boroughs

Sustain, the alliance for better food and farming, was commissioned by London boroughs to run a project which would support them to publicly commit to reducing sugar and promoting healthier food through signing up to a joint declaration. The project involved extensive consultation to shape the declaration, involving the Association of Directors of Public Health, London Councils, the Greater London Authority, the VCSE sector and a range of specialists in the area of nutrition. Sustain has also developed a support pack and helped to launch the initiative.

The declaration requires councils to implement at least six different actions from a menu of six key areas and to make an annual report on progress. The key areas are:

1. Tackle advertising and sponsorship.
2. Improve the food controlled or influenced by the council and support the public and voluntary sectors to improve their food offer.
3. Reduce the prominence of sugary drinks and actively promote free drinking water.
4. Support businesses and organisations to improve their food offer.
5. Healthier food and drink at public events.
6. Raise public awareness.

Examples of activity include:

- Ensure all food and beverage advertising in publications, events, billboards, bus stops and others under the control of the council includes nutrition information.
- Remove vending machines offering food and drinks high in sugar, fat and salt from council run premises or commissioned services.
- Promote voluntary ‘sugary-drinks duty’ to local businesses, such as convenience stores and restaurants.

The initiative was launched in November 2016 at City Hall, and the declaration will now be considered by London’s councils.

Contacts

Sofia Parente, Sustainable Food Cities Campaigns Coordinator Email: sofia@sustainweb.org

Jane Connor, Health Improvement Principal (Healthcare), Royal Borough of Greenwich Email: jane.connor@royalgreenwich.gov.uk

RoSPA – national charity working with national and local government to prevent accidents, save lives and reduce injuries

The Royal Society for the Prevention of Accidents (RoSPA) has a long heritage of working with local authorities and partners across the UK to improve the public’s health in areas such as public health prioritisation, developing accident prevention strategies, delivering projects, and evaluating outcomes. There is a particular focus on home safety, road safety, water safety and trading standards. RoSPA is marking its centenary during 2017. The following are two recent public health initiatives. Preventable mortality, morbidity and local public health priorities

Developed by RoSPA in 2014 as a prioritisation tool, ‘matrix workshops’ have been trial led by local authorities to review local public health investment priorities. The matrix is a decision-making tool that is the synthesis of three proven methodologies: Programme Budgeting and Marginal Analysis, Save to Invest, and Multi Criteria Decision Analysis. Workshops are held with 10 to 20 local experts, and local data is extracted and analysed using the Office for National Statistics’ definition of preventable mortality to focus on preventable deaths, hospital admissions and A&E attendances. This allows the experts to build a consensus around the relative priorities of the 12 main causes of preventable mortality and morbidity, starting with the number of deaths. The exercise is finished by prioritising the causes by their return on investment. The results among pilot authorities – Halton, Shropshire, Blackburn with Darwen – are consistent, and suggest that a significant change of priorities would deliver improved returns for local communities in terms of reductions of preventable mortality and morbidity.

Stand Up, Stay Up falls prevention programme

Falls in older people are a major concern, bringing both high personal and economic costs. The health and social care costs of a hip fracture is estimated at £20,000. Older people visiting A&E as a result of home accidents are more likely to be admitted than any other age group. RoSPA has been actively involved in delivering falls prevention strategies, and delivers accredited falls prevention training across the country. In 2016 RoSPA received significant funding from the search DH aimed at reducing the number of people killed and injured by falls at home, resulting in the development of Stand Up, Stay Up. The project aims to work closely with partners in 10 local authority areas in England to enhance innovative programmes to reduce falls and provide people with the knowledge and support they need to keep themselves safe. A network of professionals is also being created to enable the sharing of best practice.

Learning and messages

RoSPA believes that it makes sense for public health to operate in local government where it is well placed to influence the wider determinants of health and to ensure better coordination of initiatives across the area.

However it is concerned that funding cuts both to local government as a whole, and now public health budgets, mean that progress is slow; also many highly effective accident prevention initiatives are facing reduced resources and are either closing or struggling to keep going.

RoSPA is calling for greater national and local recognition of accidents as the leading cause of preventable mortality and morbidity, and having a major impact on A&E attendances. It recommends that investment should be made to tackle this, and has identified measures to particularly reduce accidents to young children, teenagers and young people, as well older people.

Contact

Jo Bullock, Head of Communications, RoSPA Email: jbullock@rospa.com Commissioning and new delivery models

The shift to local authorities, with their expertise in commissioning and contracting, has enabled public health to undertake competitive tendering for major service areas. Some public health teams have, so far, focused on one service area, others have carried out across the board reforms. The main services that have been reviewed and recommissioned include: substance misuse, sexual health, early years/0-5s and integrated wellbeing services.

There is still some use of grant-funding in public health, but this is generally within the context of stimulating community development or piloting short-term initiatives; this is discussed in the section on community-centred approaches.

Commissioning and re-commissioning

The need to refresh provision Public health teams were recommissioning services with some or all of the following aims:

• integrate and coordinate services which were seen as unconnected • develop services that are more person-centred and flexible • refocus services on delivering measurable outcomes • put greater emphasis on prevention • target services at areas facing greatest health inequalities • deliver innovations, such as apps to book appointments • shake up providers seen as providing below par services • make budget savings.

In many areas, public health has welcomed the opportunity to make changes, particularly in relation to large contracts that were seen as being subject to very little challenge in the NHS. Sometimes, councils’ commissioning and contracting procedures were seen as being able to ‘rattle the cage’ of providers that were viewed as being able to perform more effectively. Where this applied to large NHS providers, competitive tendering was seen as a tool to encourage them to deliver a more responsive service or face losing the contract. In many cases this has led to more partnerships with the VCSE sector.

Comprehensive, inclusive commissioning and re-commissioning

Competitive commissioning and re-commissioning can be a stressful process for providers. Some respondents to the ‘National VCSE Review’ pointed to concerns about short term funding, disproportionate processes – impenetrable bidding processes and managing contracts worth a few thousand pounds as if they involved millions – and opaque decision making.

However, it also provides opportunities for new providers to show what they can do, and creates a fair environment which is often appreciated by the VCSE sector. Public health teams in the case studies were very mindful of the tensions involved, and spent a great deal of time preparing for and carrying out well-considered commissioning and contracting exercises. Both one to one and group meetings were needed, and it was also important to give consistent clear messages about what public health wanted to achieve. In re-commissioning, they aimed to respect the expertise and understanding of current providers while also seeking the views of a wide range of other stakeholders, particularly current and potential service users. Other key approaches were to analyse performance information, circulate information to a wide range of stakeholders in a transparent way, and involve providers in the development of service specifications.

In Birmingham, service reviews were extensive, with detailed analysis of data, helped by public health intelligence staff based in the council’s Commissioning Centre for Excellence. There were also comprehensive consultations – both with the public, people who use services, and providers – which fed into the co-design of emerging service models and outcomes. Each redesign workstream involved a strategic board with representation across the council.

In Leeds, the recommissioning of community-based healthy living services, held in 14 different contracts, involved a range of mechanisms to involve current and potential providers. This process was built upon long-standing and close relationships with the VCSE sector and discussions about how to ensure that their valued contribution to health and wellbeing could be sustainable. Mechanisms included:

- stakeholder information and engagement sessions to consider current and future need
- service review findings published and freely circulated
- draft specification published for comments, some of which informed the final document
- a bidder information event to ensure that everyone received the same information.

A common dilemma faced by many areas was how to create a fair balance between the rules of competitive tendering, needed either because the size of the contract required this or to encourage a wider range of providers to become involved, and the move to coproduction with the VCSE sector and other stakeholders. This is particularly important with services that are based on close connections with local communities.

In recent guidance on commissioning for better health outcomes, the LGA advises that commissioning should not be regarded as a ‘narrow activity focused on securing services from an external provider’11. Rather it should be developed in the context of a wider strategy, and different parts of the local system should be brought together in a culture of trust to work on the best solutions to complex issues. Principles of good commissioning are:

- act as system leaders to build the right culture, relationships and partnerships
- have a clear focus on outcomes
- take time to understand what is driving population behaviour
- invest strategically and for the longer term
- work with communities and build on assets
- work with providers as partners and shape the market
- commission across systems and whole pathways for prevention
- use evidence of what works and build new evidence through evaluation.

To make sure that procurement facilitates improved outcomes, rather than being overly focused on process, it is important for public health to work closely with council commissioning and procurement teams from the outset. Clarity is needed over matters such as whether competitive tendering is a requirement, and, if not, whether it is the best option, and to agree a way forward for the maximum involvement of the VCSE within procurement rules. Greater understanding of commissioning and procurement processes would be beneficial to public health teams, particularly for staff who have regular contact with VCSE and other independent providers.

While overall, public health teams were pleased

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10 LGA (March 2017), Public health transformation four years on: maximising the use of limited resources http://www.local.gov.uk

11 LGA (2016), Commissioning for better health outcomes http://www.local.gov.uk/web/guest/publications/-/journal-content/56/10180/7954763/PUBLICATION with the results of commissioning exercises, there were occasional instances of unintended consequences. For example, where a valued organisation did not submit a bid, or where there were insufficient bids to provide a real choice. Understanding the contracting process will, to some extent, help with such issues.

New delivery models

Several new delivery structures that enable VCSE organisations to take a greater role in service delivery are emerging from commissioning exercises. These reflect the fact that tackling complex issues often requires a number of different, but coordinated, approaches to make the best impact.

There are many variations on this, but these may be based on some form of lead provider role in which one organisation takes overall responsibility for service delivery in order to provide a joined-up service across one or multiple providers. There are examples of lead providers from the statutory sector, such as foundation trusts, and from the VCSE sector. Some are partnerships of two organisations, others are larger consortia.

In Birmingham, the lead provider for the integrated, recovery-focused substance misuse service is the national charity, Change Grow Live, which subcontracts with other local voluntary and community organisations.(^\\text{12})

In Somerset, Somerset Partnership NHS Foundation Trust was appointed lead provider for the integrated sexual health service, SWISH, with voluntary organisation Eddystone Trust responsible for preventative services.(^\\text{13})

In Cheshire East, the contract for coordination of the One You Cheshire East integrated lifestyle and wellness support system, which is provided by a range of statutory and VCSE providers, was won by PEAKS & PLAINS Housing Trust, working in partnership with Age UK Cheshire East.

In many areas, VCSE organisations have a significant role in public health provision – as a system-wide leader or coordinator, as provider of major contracts, and also in specific, community facing roles. In relation to the latter, VCSE organisations are often seen as providing a niche service, better able than large statutory agencies to engage with communities and encourage peer support and volunteers. Examples of these services include breastfeeding support, and sexual health services with young people.

Impact of new arrangements

It is highly likely that many of the new partnership arrangements will be untried and untested. For example, NHS foundation trusts are unlikely to be the most natural partners of relatively small VCSE organisations – both are likely to be unfamiliar with each other and to have completely different ways of working. In some cases these relationships, and those between consortia of VCSE organisations, may be relationships of convenience brought about by the need to respond to bids. To make them work as effective partnerships delivering truly integrated services will take work from both commissioners and providers themselves, particularly in the early stages. New arrangements also have an impact on the VCSE sector – overall working more closely together will bring about benefits – but there are winners and losers. These issues are considered in following sections of this report.

A strategic approach to working with the voluntary and community sector in Leeds – opportunities and challenges

In 2016, Leeds Public Health undertook a strategic review and recommissioning of its community-based healthy living contracts, in which 14 individual contracts were held by 11 separate providers.

(^{12}) LGA (March 2017), Public health transformation four years on: maximising the use of limited resources. http://www.local.gov.uk

(^{13}) ibid. The review had several aims including:

- services would be designed to best meet Leeds’ Health and Wellbeing Strategy outcomes – particularly reducing the difference in healthy life expectancy through targeted action
- services would be value-based – higher outcomes at lower cost
- the voluntary and community sector would be supported to be sustainable for the future.

**Review findings**

One implication of the review was the need to redistribute and better target available funding to areas of highest deprivation. This meant that one area would receive significantly less funding. Local public health specialists had worked closely with providers and local leaders over the course of the previous contract and throughout the review, so although disappointed they understood, and agreed with, the broader direction to reduce health inequalities.

Through the review it became apparent that the focus of the service should widen beyond providing healthy living activity, such as setting up group activities to increase physical activity levels. The new service would also include building social capital, increasing individual and community resilience, and tackling the wider determinants of health such as financial exclusion, poor housing, worklessness, mental health problems and cultural differences. For example-linking people with activity that would help them to manage their finances.

Due to ongoing funding reductions, the new contracts would have a value of 10 per cent below the sum of the old contracts. However, commitment to the VCSE sector was demonstrated by extending the contract length to three years, with an option for a further two years.

Public health has been developing an outcome-based and person-centred approach to monitoring contracts with providers since 2013, and this tool will be used for the new service. The Wellbeing Wheel encourages service users to think about changes they would like to make across several areas of their life, such as social networks, money, housing, and physical/emotional wellbeing. The Wheel is then used as a basis for setting and achieving steps for change. Anonymised data provides commissioners with information about the complexity of needs in the most deprived communities, and about the sustained support undertaken by providers.

**Procurement process**

**Rationalising contracts**

The 14 contracts were historical and had been established originally to target particular geographical areas and communities. The review process led to an options appraisal which resulted in a recommendation of having three locality-based contracts, one for each of the three geographical areas of the city. The trend for fewer, larger contracts is emerging as a direction of travel in Leeds. Whilst this provides savings for commissioners, for the voluntary and community sector, which has multiple small organisations, securing such contracts can be problematic, so public health worked with the sector to develop capacity.

Some providers were already in consortia arrangements and those that were not, were encouraged to consider their risk of sustainability, including their ability to compete with, or join consortia arrangements. Also, a number of sessions were held with present and potential future providers to describe the function of the contracts.

An advantage of consortia arrangements is that they are expected to provide stronger voluntary and community sector infrastructure, greater sharing of skills and expertise, less duplication and a stronger shared voice. Voluntary and community sector public health providers in Leeds are said to understand the benefits of continuous development in how they work, and are generally willing to do so. Balancing relationship management and procurement rules The review and re-commissioning process was conducted under stringent council procurement conditions, the public health team being guided by council procurement professionals to ensure the process and subsequent outcome was fair, equitable and impartial – providing a level playing field for both current and potential future providers to construct credible bids.

The challenge was to remain engaged with current and potential local providers with a long-standing commitment to community wellbeing so that their expertise could inform the future service. To achieve this, a series of opportunities for VCSE providers and service users/community members to contribute to the review and subsequent specification development were set up:

- current providers completed a service review template
- provider annual report submissions were analysed
- community surveys were conducted
- service user focus groups were held
- service review findings were published and freely circulated.

Other ways of involving existing and potential new providers included inviting comments on a draft specification and bidders information events.

The new service, which is seen as providing the foundations upon which all other aspects of health can be built, will dovetail with the full range of other services provided in local communities such as housing, the Integrated Healthy Living Service which was also being recommissioned, and CCG services such as social prescribing.

Post contract engagement A provider’s introductory event welcomed new providers and set out the requirements for a six-month mobilisation period, prior to the new service going live in April 2017. Public health is continuing to work closely with the successful providers to co-produce the final version of the service. So far, a series of contractor forums, each providing targeted guidance on key requirements, such as branding and communications, evaluation and asset based community development have been delivered, along with one-to-one provider/commissioner meetings.

Learning and messages Although this has been a stressful and uncertain time for providers, there has been positive feedback from the VCSE sector in relation to how public health was willing to work in partnership and take their views into account when developing the service specification.

Overcoming the challenges in this process of significant change involved extensive, close working with providers and other stakeholders. It has required public health to give consistent, clear messages about what they want to achieve from the recommissioning, but also to incorporate the expertise from VCSE organisations and other stakeholders, gained from their experience of working with communities. It needed honesty about the financial position, but also a commitment to the future sustainability of the VCSE sector which is seen by Leeds City Council as an essential partner for service planning and delivery.

Contact Elizabeth Bailey, Health and Wellbeing Improvement Manager, (East North East), Leeds City Council Email: elizabeth.bailey@leeds.gov.uk

Strategic partnerships in Tower Hamlets London Borough of Tower Hamlets has a long-standing relationship with the VCSE sector, and is keen to support the development of highly skilled, responsive organisations which can contribute to the range of service provision, both across the borough and in local communities. In the council, this work is led by the Strategy, Policy and Performance division and delivered through the Third Sector Team, both of which the public health team works closely with.

Tower Hamlets has an active Council for Voluntary Service, THCVS, which runs organisational support and development activity, a service directory, and a range of forums for networking and practice development, including an active health and wellbeing forum. THCVS employs a health lead, supported through CCG funding, who acts as a link and represents the sector on the HWB and other key strategic groups and increases the understanding of the sector within statutory organisations.

Public health funds a significant amount of activity in the local VCSE sector, and since moving to the council this has expanded. The team has reviewed several service areas with the overall aim of delivering integrated services which are accessible to users and have links with communities. This has helped contribute to the development of several new organisations and new delivery models.

For example, following open procurement, Barts Health was appointed lead provider of an integrated sexual health service. As part of this, to meet the specific needs young people, the VCSE organisation Step Forward was chosen to provide a dedicated sexual health service for people under 25. This includes access to an advisor or a medical professional, contraception, STI screening and self-testing, as well as counselling, personal development and a service for lesbian, gay, bisexual, transgender and questioning young people. Similarly, Tower Hamlets' weight management service is a joint commission between a VCSE organisation and an NHS acute trust.

As well as commissioning services, public health has strong links to VCSE organisations through their locality managers who work on place-based health and wellbeing issues. In addition, a public health specialist registrar (trainee consultant) was placed within two local organisations. The aims were to increase the registrar’s understanding of the VCSE sector and its contribution to health and wellbeing, and to work with local organisations to increase their understanding of the statutory sector, national policy changes and local population health priorities. This placement worked with partners through the THCVS Health and Wellbeing Forum.

While the transfer of public health resulted in an expansion of activity, the overall picture is that continuing years of financial cuts to the council are having an impact on all service provision. At this difficult time, the council is seeking to support VCSE so that it remains strong, independent, and geared up to work in partnerships. A three-year VCSE Strategy has been developed which aims to:

- promote co-production and sustainability
- maximise the value of resources
- create a sea-change in volunteering
- and bring together businesses and VCSE.

As part of this, the council will continue to shift from grant funding to a procurement model which emphasises co-production and enabling organisations to cooperate rather than compete for funding – for instance working as consortia. Public health has helped shape this strategy, which will be important for the commissioning and re-commissioning exercises that will take place in the coming years.

The Compact is an important part of how the council and the VCSE sector work together. As part of the delivery of the VCSE strategy, the council is working with the VCSE sector to renew the Compact in order to better reflect new ways of working together and shared aspirations and commitments.

Public health is also supporting the health and wellbeing board (HWB) to develop a new Health and Wellbeing Strategy for 2017/18 which will focus on a smaller number of key priorities such as employment and children’s weight and nutrition. One of these priorities is ‘communities driving change’. This includes developing new approaches such as those piloted by the Well London programme, and a new ‘health creation’ programme.

Health creation is the result of a set of approaches to empower local people and communities to take control over their lives. and their environments. A key element of this is improving how local people and services listen to each other so that together they can create the conditions for health and wellbeing. This involves shifting focus from ‘engaging’ and ‘involving’ residents to supporting them to become active, and to take a lead in improving things that matter to them. A national model underpinning health creation is C2 Connecting Communities.

Learning and messages

• It is helpful to have a dedicated health lead in the VCSE sector to ensure that the sector is well engaged in health and wellbeing developments.

• Placing the public health registrar with local organisations has resulted in much greater mutual understanding of roles and responsibilities.

• New contracting partnerships between VCSE organisations and NHS providers, which may have had no previous relationship, will need to be supported by commissioners to reinforce the value of joint working and address any problems arising from misunderstandings between very different organisations.

• New public health models like ‘health creation’ require organisations to make a fundamental shift in how they operate, and are likely to be challenging to develop.

Contact Abigail Gilbert, Public Health Locality Manger, SE Locality Email: abigail.gilbert@towerhamlets.gov.uk

John Gillespie, Health and Wellbeing Officer, THCVS Email: john.gillespie@thcvs.org.uk Supporting a sustainable future

Although the first few years post-transfer have been a time of expansion for the VCSE sector providing public health services, ongoing funding constraints mean that, in many areas, further developments, and even the current range of provision, are under question. Re-commissioning exercises are often undertaken within a smaller financial envelope than for the existing services, and new commissions are done with great emphasis on cost. In addition, the shift towards delivery models that support integration, such as consortia and partnerships, requires the VCSE sector to adapt how it operates – not just in relation to public health but in other service areas like adult social care. This is therefore a time of significant change and concern for the sector, and for public health, which is seeking to maintain capacity in a diverse and capable VCSE sector.

Financial sustainability To address these issues, some local authorities and public health teams have been proactive in working with the sector to identify ways in which it can remain strong, independent and sustainable in the longer term.

An important part of this is for both parties to understand each other’s perspective. Public health seeks skilled, flexible, cost effective service providers. The VCSE sector shares these aims, but also wants financial security, rather than the constant pressure to seek funding sources. It also wants councils to be transparent in their dealings, and to be given a reasonable amount of time to adapt to new requirements. The ‘National VCSE Review’ recommends that longer term funding should be standard, and areas should consider capacity building support, particularly for smaller or specialist organisations.

While nearly all areas have an established Compact, some are also looking at initiatives to bring more clarity to their relationships.

In Tower Hamlets, the council has worked with the voluntary sector to develop a three-year VCSE strategy to set out context for commissioning and relationships in the coming years. This identifies that the council will continue to the shift from grant funding to a procurement model based on co-production and enabling organisations to cooperate rather than compete for funding, for instance working as consortia.

The multi-award winning New Realities agreement was developed in Sefton by the council and the CVS in order to strengthen their working relationship. The agreement is based on the fact that resources are scarce, so the borough needs to use all its assets and to create an enabling culture in which skills, expertise, solutions and costs are shared. An important element of the agreement is ensuring that the council has a light touch with community initiatives that make life better for local people – moving from a gatekeeper, focused on potential blocks to action like health and safety or insurance, to an enabler that seeks to reduce barriers.

Many councils have moved to longer-term contracts for the VCSE – for example, both Sefton and Cheshire East have funded three-year contracts for integrated healthy living services.

VCSE contribution to funding It is important to recognise that funding can be a two-way rather than a one-way street. VCSE organisations have the potential to tap into funding streams that are not available to public health, but which make a great contribution to health and wellbeing. outcomes. A dynamic, well-organised VCSE infrastructure organisation is extremely helpful in supporting the sector as a whole to find funding opportunities, including a better relationship with the local business sector.

Social Finance, a not for profit organisation that works with national and local partners to tackle social problems, worked with Age UK Herefordshire and Worcestershire to design a service model to help older people overcome loneliness in Worcestershire. The county council, and three CCGs agreed to jointly commission the Reconnections service, with initial funding through the Reconnections Social Impact Bond. The Cabinet Office and Big Lottery Fund also contribute to payments.

Norfolk has an active Warm and Well Partnership involving the county council, district councils, the NHS, the VCSE sector and others, which is committed to improving the health of vulnerable people through better housing, reducing excess winter deaths and reducing fuel poverty. In 2016, public health supported voluntary and community infrastructure organisation Community Action Norfolk, to make a successful bid for external funding to extend warm and well activity.

The VCSE sector as a whole can also make an important contribution to more cost effective and better quality local provision.

In Brighton, Citywide Connect is a network which brings together staff from the council, the NHS, the VCSE sector and independent providers of services for older people with the aim of identifying ways of working more effectively together at a time of reducing resources and growing demand. An independent evaluation of the first two years found that network members working together had made many improvements, including work to tackle loneliness and a common assessment form and referral pathway. While it is not possible to directly attribute savings to the work of the programme, a very approximate estimate suggests potential savings in the region of £12 million a year.

Evaluating programmes Demonstrating the value and impact of interventions is essential for securing funding, and also contributes to the evidence-base to improve approaches in the future. Some areas of prevention – such as supporting behaviour change in people with complex needs over the longer term – are particularly difficult to assess. Public health teams are working on performance frameworks which can catch more subtle outcomes.

Leeds public health has worked with providers to develop an outcome-based and person-centred approach to monitoring contracts. The Wellbeing Wheel encourages service users to think about changes they would like to make across several areas of their life, such as social networks, money, housing, and physical/emotional wellbeing. Anonymised data provides commissioners with information about the complexity of needs in the most deprived communities, and about the sustained support undertaken by providers.

Evaluation can particularly challenge smaller charities. Larger organisations are used to reporting requirements from national bodies and local government, and may have developed sophisticated evaluation methods. Smaller charities have far fewer resources. A study commissioned by NAVCA suggests that there is a danger of commissioners disinvesting in small organisations that are actually producing good outcomes.14 Infrastructure organisations and councils both have a responsibility to ensure that smaller charities are helped to be able to demonstrate what they have achieved.

Collaboration rather than competition Most local VCSE organisations operate with marginal funding, and securing contracts is often essential for survival and for their workers’ jobs. Also in many areas, local government and the NHS have contributed to an ethos of competitive commissioning. Fortunately, this is now changing.

14 NAVCA (2016) In sickness and in health https://www.navca.org.uk/news/264-demonstrating-impact-essential-for-smaller-charities In the case studies in this report, both public health and the VCSE sector favoured an environment in which organisations were encouraged to collaborate and cooperate rather than compete. A key way of promoting this is to encourage organisations to join together in consortia, and both councils and VCSE infrastructure organisations have been active in supporting this development.

There are many advantages in a consortia approach. The potential for duplication is reduced, and skills, expertise and capacity can be combined, allowing organisations to undertake larger or more complex contracts.

Age UK Cheshire East and PEAKS & PLAINS Housing Trust have operated a long-standing partnership which developed a model that has been successfully used across several public health and social care services. Age UK Cheshire East is ‘community facing’, providing direct work with individuals of all ages, while PEAKS & PLAINS provides a bespoke IT service capable of producing a range of data from multiple agencies.

The VCSE organisations spoken to in the course of this report welcomed the move towards partnerships and consortia, and recognised the benefits they brought – provided they were done fairly and were handled in a way which allowed the sector time to organise itself effectively. There was some concern in respondents to the ‘National VCSE Review’ that large, multi-agency contracts could lead to less innovation.

Clearly there are potential winners and losers in this approach. Some VCSE organisations are large, professional and geared up to scanning the horizon for opportunities. Some smaller organisations, which may be working very effectively with their communities, do not have the capacity to go far beyond delivering their front-line services. If developed thoughtfully, consortia should help with this – enabling smaller organisations to work with, learn from and contribute to the work of bigger ones, while maintaining their own geographical or user-group links.

The role of infrastructure organisations Infrastructure organisations have an important role in supporting the sustainability of their local members, helping them to see the bigger picture in relation to local strategic development of health and care, and to develop their own understanding of where they want to fit in service delivery.

Research by NAVCA(^\\text{15}) indicates that there is a relationship between the level of targeted infrastructure support and the ambition and confidence of VCSE organisations to take on new commissioning opportunities. It also suggests that infrastructure organisations are most effective when they assume a brokering role between commissioners and contractors.

Across the country there are examples of the VCSE sector re-shaping itself to better meet future needs, and some of these are reflected in the case studies in this report. Some organisations that focused on a limited geographical area are now looking to widen their reach – some with an eye on STP footprints and devolved areas. New not for profit organisations, including social enterprises and community interest companies, are being established. Some VCSE organisations are looking to widen their remit, sometimes through changing their constitutions, so they can operate across a wider user group or area.

Market development – commissioners working together The VCSE sector is made up of charities and not for profit organisations that are proud of their independence, so working with an effective infrastructure organisations is often the most effective way of supporting development in the sector. However, public health also has an important role in this. As commissioners responsible for ensuring the provision of effective services to improve health and wellbeing at the best cost to the public pound, public health needs to support market development. This may involve

(^{15}) NAVCA (2016), Health and local infrastructure. https://www.navca.org.uk/resources/134-health-and-local-infrastructure nurturing key organisations, supporting the development of new ones, and considering whether involving regional organisations may bring expertise to reinvigorate local provision. Public health will also want to encourage the development of smaller groups which are able to work closely with people facing health inequalities and those at risk of social exclusion.

Public health also has a role in tackling local problems including potential challenges emerging from the latest policy landscape including:

- social prescribing referrals to VCSE organisations that are not receiving payment for additional activity
- consortia approaches that leave organisations outside the group behind – the ‘us and them’ of single organisations becomes the ‘us and them’ of consortia
- organisations destabilised by badly timed de-commissions
- lack of understanding of, and information about VCSE organisations in GPs
- an infrastructure organisation not geared up to supporting the sector to be energetic and innovative.

These are issues for commissioners to tackle by taking a whole-system approach to market development, based on intelligence from the JSNA process, which is best undertaken in partnership with other key commissioners, particularly adult social care and CCGs. These commissioners are fishing in the same VCSE pool with slightly different, but often complementary goals. By working together they can produce synergies and avoid or deal with problems. For example, councils have a responsibility to ensure choice in adult social care through the ‘market diversity’ measure in the Care Act 2014. With many adult social care services having a preventative element, public health and adult social care need to work together. Similarly, commissioners need to work in partnership on developing community-centred approaches, and in commissioning for social value, below.

**Implementing the Social Value Act**

The Social Value Act 2012 (the Act) requires public sector commissioners, including local government and the NHS, to consider economic, social and environmental wellbeing in the procurement of services and contracts. Potentially, the measures in the Act could bring benefits for both the health of communities and for the sustainability of the VCSE sector.

PHE and University College of London’s Institute of Health Equity (UCL) have produced a paper setting out how defining social value with reference to the social determinants of health could bring a range of benefits, such as helping reduce local health inequalities, improving health and wellbeing in local people, and, over time, reducing demand on health and care services. Examples include employing local people, targeting groups such as unemployed young people, building local supply chains and procuring with the VCSE sector.

Unfortunately, it seems that the Act is being used in only a limited way. A review by Social Enterprise UK (SEUK) indicates that only one in three councils routinely consider social value in commissioning. Some councils have a social value policy which is regularly applied across all procurement, and which may score social value as high as 30 per cent in assessing contracts. But others’ use of social value is much more limited, and some appear not to be applying the Act at all. The ‘National VCSE Review’ recommends that local authorities and the NHS should embed social value in their commissioning approaches.

PHE and UCL report that those who have been proactive in embedding social value identify the following success factors;

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16 Think Local Act Persona, TLAP (2015) Top Tips: commissioning for market diversity http://www.thinklocalactpersonal.org.uk/Latest/Top-Tips-Commissioning-for-Market-Diversity/

17 PHE and UCLIHE (2015), Using the Social Value Act to reduce health inequalities in England through action on the social determinants of health https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/460713/1a_Social_Value_Act-Full.pdf

18 SEUK (2016), Procuring for good: how the social value act is being used by local authorities http://www.socialenterprise.org.uk/uploads/files/2016/05/procuringforgood1.pdf involving a range of staff including health and public health, building community involvement and producing a social value policy or framework. Areas for further work include measuring impact through existing methodologies such as Social Return on Investment, using existing Key Performance Indicators (KPIs) or designing local measurement systems to build evidence to support the case for social value approaches.

Public health may find it useful to work with their council to consider how the Act can be used to promote health and wellbeing and tackle the social determinants of health. The social value hub has case studies of how areas have used social value in the areas of health and social care.

The national VCSE Health and Wellbeing Alliance

Building on a recommendation in the ‘National VCSE review’ that funding should be distributed to the VCSE in a way that achieves maximum impact, the DH, NHS England and PHE have launched a new VCSE Health and Wellbeing Alliance19 for 2017/18. Through the alliance they will work with the VCSE to “promote equality and address health inequalities and help people, families and communities to achieve and maintain wellbeing”. This will become a key mechanism for supporting the work of the VCSE sector at national level, and the work of the alliance will be of interest to local areas.

Healthy homes and warm and well in Norfolk

Approximately 35,700 households in Norfolk live in fuel poverty, representing around 9.3 per cent of the county’s households and rising to 11.5 per cent in Norwich and Great Yarmouth. In addition, Norfolk’s extensive rural areas have an above average use of electricity and oil for heating.

To tackle these problems, Norfolk has an active Warm and Well Partnership involving the county council, district councils, the NHS, the VCSE and others, which is committed to improving the health of vulnerable people through better housing, reducing excess winter deaths and reducing fuel poverty. The partners work in a steering group which coordinates action, and utilises the skills of the different organisations to contribute to overall shared health outcomes.

For example:

- Public health provides intelligence on winter deaths and identifies priority areas so resources can be targeted. It also analyses national good practice to underpin the local action plan, and supports partners to implement Norfolk’s ‘Stay Well this Winter’ campaign which is based on the national PHE campaign and resources.
- District councils provide access or signposting to services such as emergency housing repairs, low level insulation, befriending and debt advice, working closely with district VCSE organisations.
- The VCSE provides a range of services, and in 2016 was involved in a major funding bid.

In 2016, public health faced the need to reduce budgets, including the Warm and Well budget. Public health supported voluntary and community infrastructure organisation, Community Action Norfolk (CAN), to bid for other potential areas of funding. CAN made a successful bid for British Gas Energy Trust ‘Healthy Homes’ funding to tackle fuel poverty and to support the Stay Well this Winter campaign. The one-year funding provides the following services:

- training for front-line staff in how to support those in fuel poverty
- a small grants fund for communities to make a difference
- exploring the use of new technologies in monitoring the most vulnerable, such as use of a thermal imaging camera
- support for maintaining the efficiency of homes, particularly in ‘off-gas’ and rural areas.

19 https://www.gov.uk/government/publications/VCSE-health-and-wellbeing-alliance-application-form See resources section for contact Headlines from the programme evaluation include:

- Three hundred and fifty front-line staff trained in basics of fuel poverty, cold related health impacts and saving energy and money, with 100 per cent of those providing feedback saying their knowledge had increased and they felt more able to help clients.
- Greater cooperation across agencies and districts including shared information, shared initiatives and increased opportunities to develop internal services such as handyman schemes.
- Piloting of social prescription models in Norwich and extending existing pilots in South Norfolk to concentrate on energy related illness and issues.
- £200,000 spent on home improvements and repairs across all seven districts ranging from low level adaptions to replacement heating systems.
- £10,000 community funding supporting a range of initiatives from the development of ‘fuel banks’ to extended fire safety checks.
- Targeted winter warmth campaign on areas of high excess winter death.

CAN also secured funding from the Big Energy Saving Network and energy best deal campaigns to provide training to consumers and local groups across Norfolk to help people to understand the health risks presented by a cold home, save energy and save money through switching suppliers and claiming benefits. CAN has also identified a source of further funding for 2017.

Due to its size, rurality and areas of deprivation, Norfolk is a challenging environment for promoting health and wellbeing. Partners need to take a holistic view of all the elements involved in helping vulnerable people to stay well over the winter. For example:

- refuse and recycling services are involved in identifying vulnerable people, and providing Stay Well information
- referral routes to greater support are coordinated
- multi-agency events providing a range of health and wellbeing interventions such as slipper exchanges and mini health checks are organised
- an annual conference examining national and local good practice takes place.

The partnership steering group is now moving on from a focus on winter warmth to looking at housing and health needs throughout the year, becoming the ‘Healthy Homes’ partnership.

Learning and messages

The partnership between public health and the VCSE sector brings mutual benefits – both share similar aims for improving health, and the ethos in Norfolk has been, ‘let’s do it together’. Public health and the VCSE sector tend to be complementary, so can combine areas of strength. For example, VCSE organisations are able to respond quickly and take risks, and can apply for a wide range of funding; public health has specialist expertise, can access national sources of information and support through PHE and can utilise the resources and assets of the full council.

In developing the partnership it has been important to understand each other’s points of view, including the challenges facing VCSE organisations and public health. Differences of opinion are inevitable but mutual understanding can minimise these and help find solutions. At a time of budget cuts, is particularly important to establish a co-production approach based on both valuing each other’s contribution.

Contact Sean Christie, Public Health Officer, Healthy Places Team, Norfolk County Council Email: sean.christie@norfolk.gov.uk

Rik Martin, Operations Manager, CAN Email: rik.martin@communityactionnorfolk.org.uk Social investment to tackle loneliness in Worcestershire

Loneliness is increasingly recognised as having a detrimental effect on many aspects of people’s physical and mental health. Social Finance, a not for profit organisation that works with national and local partners to tackle social problems, worked with Age UK Herefordshire and Worcestershire to design a service model to help older people overcome loneliness.

Following detailed discussions, Worcestershire County Council, and three CCGs agreed to jointly commission the Reconnections service, with initial funding through the Reconnections Social Impact Bond. The Cabinet Office and Big Lottery Fund also contribute to payments.

Social impact bonds are designed to develop preventative services which need upfront funding. Investors fund the service cost and commissioners only pay when and if an outcome is achieved. The investors in the Reconnections Social Impact Bond are Nesta Impact Investments, the Care and Wellbeing Fund, and Age UK national.

Age UK Herefordshire and Worcestershire was appointed as the lead contract holder, with six additional local VCSE organisations as delivery partners. The service started in 2015.

The model The service aims to address loneliness by connecting isolated individuals with people, places and activities in their area. There are four steps in this:

Referral: the service is marketed widely in local services and media outlets; referrals come from the NHS, adult social care, the VCSE sector, self-referrals, and families and friends.

Assessment: older people are typically supported with telephone triage in which they are checked for eligibility and their baseline loneliness score is recorded using the UCLA scale. A face to face home visit is then scheduled where an assessor seeks to understand the individual’s needs and co-produces a personal plan to reduce loneliness.

First step activities: the VCSE delivery partners recruit volunteers who work alongside the individual to implement their plan, helping them to engage in activities in the local community, such as gardening clubs or singing group. Some people prefer to start with a befriending service to gain confidence, and some are referred to groups, such as communication skills or CBT/self-help groups.

Being better connected: a six month review takes place to look at progress and any ongoing support needs, with the option to extend the service. The intention is that the older person will reconnect with their communities and go on to establish their own social contacts. Some people with more long term complex needs may be referred for further support. Some may wish to join Reconnections as a volunteer and give something back to others.

By the end of 2016, 1,110 referrals had been received from over 100 different local organisations, over 800 assessments had taken place, nearly 600 individuals had been supported by volunteers, and around 10 older people went on to become volunteers.

Independent evaluation The London School of Economics Personal Social Services Research Unit (LSE PSSRU) is independently auditing the assessment process to ensure the outcomes submitted are accurate. Outcomes for individuals are measured using a standard loneliness scale at the beginning of their individual plan and at six months and 18 months. LSE is also evaluating the results of the programme overall to assess its impact on wellbeing, health and the use of health and care services. Through these measures it will draw conclusions about the overall economic impact of the programme on the local Worcestershire health and care economy. An interim evaluation by LSE has been published. Learning and messages

Many areas have services to tackle loneliness, but Reconnections can be seen as a pioneering programme for several reasons.

Building on academic studies and the work of the Campaign to End Loneliness, the project has implemented a widely accepted measurement approach which defines and quantifies the level of loneliness amongst older people. The payment by results model, based on reductions in loneliness, ensures there is continued explicit focus on understanding what is working to reduce loneliness.

The service is also aiming to deliver at scale, with 3,000 older people contacted across the county by the end of the programme. The use of volunteers is also ambitious in that, rather than befriending or home visiting, they are asked to become a key agent of change and help older people to reconnect with their community.

With its national evaluation by LSE, Reconnections aims to add to national understanding of good practice in combatting isolation. The project will provide an in-depth insight into how to understand, measure and codify the best way for volunteers and community groups to help older people to reduce their feelings of loneliness – in terms of increasing social contacts, but also considering emotional and psychological issues. It will also contribute information about the economic impact of the programme.

Contact Kendall Jamieson Gilmore, Health Advisor, Social Finance Email: kendall.jamieson.gilmore@socialfinance.org.uk

Sophie Pryce, Reconnections Project Manager, Age UK Herefordshire and Worcestershire Email: spryce@ageukhw.org.uk

Dr Frances Howie, Director of Public Health, Worcestershire County Council Email: fhowie@worcestershire.gov.uk

Further information Introduction to the Reconnections Social Impact Bond http://www.socialfinance.org.uk/introduction-to-the-reconnections-social-impact-bond/

Interim evaluation http://www.socialfinance.org.uk/wp-content/uploads/2016/08/Reconnections-Evaluation-Interim-Report_June-2016_FINAL.pdf The shift towards integrated health and well-being services has been a major theme in recent years, with most areas working to move from multiple providers delivering disconnected services. The aim of integration is to provide an easily accessible, seamless experience for service users, and simplified, cost effective contracting for councils. Integration may apply to relatively discrete service area, such as sexual health, or may pull together various services that promote health and wellbeing, such as stop smoking and weight management, so that people’s health needs are considered in a holistic way.

**Integrated health and wellbeing services**

In many areas, public health has been planning for integrated health and wellbeing services for several years, and a number of ambitious schemes, in which the VCSE sector features strongly, have been commissioned. These interesting developments shared some core features, such as a focus on building resilience and helping people learn to manage their own health, but very different models were being implemented in each area. One of the main ways in which they differed was the extent to which the integrated system was focused on behaviour change through healthy living interventions and how far it included community development approaches that were more focused on the social determinants of health. Other variables are the extent to which services are targeted or universal, and specialist or holistic.

Models considered in this report include:

Cheshire East’s One You service commenced in July 2016 and brings together a number of components provided by different statutory and VCSE organisations – stop smoking, physical activity, healthier diet, sexual health and reducing alcohol. Coordination of the service and individual lifestyle support services are provided by a voluntary and community organisation partnership. Referrals and signposting are made to other organisations that address the social determinants of health.

Durham’s Wellbeing for Life model commenced in 2015 and is delivered by a consortium of statutory and VCSE partners. It includes: one-to-one health trainer interventions with personal health and wellbeing plans; health improvement groups, such as cooking and health walks; and community health development involving a training programme for local health champion volunteers and local organisations.

Leeds’ community-based healthy living service has been refocused on the geographical areas of greatest health deprivation. It is also placing more emphasis on community development, looking at matters such as financial exclusion, poor housing, worklessness, mental health and cultural differences. The service, which will go fully live in April 2017, will dovetail with the Integrated Healthy Living Service which is also being recommissioned.

Living Well Sefton Integrated Wellness Service includes community resilience (volunteering, community navigators rolling out Making Every Contact Count (MECC)), weight management programmes targeted at children, and stop smoking services for groups such as pregnant women and people with mental health problems. The service is provided by a range of statutory and VCSE organisations and is coordinated by Sefton CVS. In December 2016, Wakefield awarded the contract for a new Social Wellbeing Service to a partnership between the local foundation trust and the voluntary and community infrastructure organisation. An important element of this will be to develop the work of community anchors, which will extend their work such as exercise classes, community cafés, childcare facilities and adult learning and skills development, with interventions to make greater use of volunteers, reducing social isolation and increasing self-management of health.

The examples above are just a few of those being implemented across the country.

**Pulling services together**

Because of the ambitious and complex nature of many integration arrangements, and the fact that new and culturally different partners may be working together for the first time, the case studies took a range of measures to develop relationships and services.

**Mobilisation period**

Most areas deployed a mobilisation period – generally six months; this was a time of co-production between public health and providers, with the pressures of the competitive tendering process removed. Areas were using the period to refine outcomes and processes, and to build a shared vision about what working together meant in practice. Public health was also monitoring and testing early operations to identify and iron out any problems that emerged.

**Dedicated coordination**

Some areas have introduced a coordinating role for complex integrated services, with an individual or an organisation responsible for encouraging different organisations to work seamlessly together. In integrated health and wellbeing services, this role is often deployed in the VCSE sector. Coordinators facilitate the process of shared training and learning that lead to effective integrated services, and which need to be delivered intensively for the first year or so until working patterns are established.

In Sefton a coordinator funded by public health and employed by Sefton CVS has been appointed to support the providers to work together. This includes training in areas such as social marketing, customer services and MECC.

**Shared IT**

A shared IT system is seen as important to help multiple organisations to work together; shared systems allow workers to input coherent data which will enable outcomes and results to be analysed within and across the integrated service.

In Cheshire East, PEAKS & PLAINS has developed a database capable of producing a range of data, including outcome measures by which to evaluate the service; workers from the provider organisations input into the database using iPads.

Sefton public health designed the ideas for their integrated IT approach through a task and finish group involving 15 potential providers. It was agreed to take the simplest approach of using anonymised data based on postcodes, setting up a central database which all providers could access. The bespoke IT system which allows providers to record consistent information went live in January 2017. In time the system will allow public health to analyse data about patterns of referral and usage to improve the system.

**Shared outcomes and performance monitoring**

Service monitoring has to be particularly vigilant in the early stages of new relationships, to help partners address any tensions that are emerging. Areas are developing shared performance frameworks as a basis for monitoring. Some popular indicators include cross-referrals across partners in the service and outcomes which reflect work in communities with people who are marginalised or who may have multiple complex needs.

**Shared processes**

Integrated services are setting up a range of standard processes, such as assessments and referral protocols in order to ensure that anyone entering the service at any access point will hear consistent messages, and receive the same referral opportunities.

In Cheshire East, the ‘One You’ lifestyle support service involves four support workers who undertake an ‘integrated threshold multi-service assessment’ to identify people who are eligible for services and support them to manage their health and wellbeing better.

In Sefton a standard script approach is being used to deliver consistency of message and referrals across all providers.

**Relationships outside the integrated service**

Integrated arrangements are designed to ensure that organisations within the system work together. However, several areas were experiencing issues with referring outside the system, with a reluctance of external organisations to accept referrals, or refusing to take referrals without payment. If such problems are persistent, there is a role for all relevant service commissioners to broker solutions.

**Integration outcomes – early days**

Most of the examples of integrated services in this report are at a very early stage of implementation, so it is not possible to evaluate what is working well. Anecdotally, in areas where services had been operating for some time, there was a feeling that the changes were resulting in positive outcomes and feedback from users.

One of the examples of integrated health and wellbeing services has been operating for nearly two years, and has also been subject to independent, academic evaluation.

Durham’s Wellbeing for Life (WBFL) service can be seen as an early implementer of integration. The area reports that, even though the five members of the WBFL consortium decided to work together, there were teething troubles because of different cultures and procedures. Problems were resolved, helped by the appointment of a coordinator, and the consortium is now functioning well.

Interim evaluation by Durham University was encouraging. It found significant improvements in self-rated health, mental wellbeing, BMI and various health-related behaviours amongst service users who completed the one-to-one WBFL intervention. BMI continued to reduce and physical activity levels continued to increase at the six-month follow-up stage, although these findings must be treated with caution due to the relatively small numbers involved.

Evaluation of these ambitious programmes is important both locally and nationally. Even though models are shaped to fit the needs of local areas, there are sufficient commonalities which mean that evaluation will provide information on what worked and what could have been done better for other areas. As a starting point for this, it will be helpful if areas allocate the resources to establish a comprehensive written framework for the programme model, beyond the information that is available in the initial service specification.

**PHE and other regional support**

External support in developing integrated services is being provided by PHE and academic institutions.

Developing integrated health and wellbeing services is being pursued by many of the councils in the North East. PHE North East is supporting the local authorities to come together and share best practice, and has coordinated regional events and practice examples to share the evidence base. It has also supported a cross-site evaluation, the development of a competency framework for the workforce, and is about to launch the community asset profiles to use for a JSNA.

The independent cross-site evaluation of North East integrated health and wellbeing services is now underway, and involves a partnership between PHE North East, local authorities and Durham and Teeside Universities.

PHE South East is working with local authorities to explore the range of integrated health and wellbeing models implemented or in development in the region to share and develop best practice. It facilitated a co-production event which considered the six critical themes identified by local commissioners: clarity on outcomes, workforce development, market development, evidence-base for cost effectiveness, community assets and promotion and marketing. Work is progressing on each of these themes.

See ‘community-centred and integrated approaches’ in resource section for contacts.

One You Cheshire East – integrated lifestyle and wellness support service

In 2015, Cheshire East Public Health undertook a consultation and procurement process on developing an integrated lifestyle and wellness support system in order to improve the health and wellbeing of communities at the greatest risk of poor health outcomes and to reduce the uptake of health and social care services.

The resulting new service, One You Cheshire East commenced in a developmental form in July 2016 and is linked to PHE’s national One You programme. It brings together a number of components: stop smoking, physical activity, healthier diet, falls prevention, reducing alcohol consumption and the NHS Health Check programme.

Public health has used a ‘provider plus’ model with a single contract for a set of core services:

- coordination and support of the One You Cheshire East system including a bespoke IT system, marketing and promotion
- a lifestyle support service provided through support workers
- a specialist stop smoking service for pregnant women and people with mental health problems, and support for universal stop smoking services such as those based in community pharmacies.

A key feature of One You Cheshire East system is that it is place-based and targeted at people in areas facing the greatest deprivation and health inequalities. The marketing and promotion function will be used to attract people from the targeted groups, and these areas will also receive a greater share of the overall funding.

The provider plus three-year contract is held by PEAKS & PLAINS Housing Trust which works in partnership with Age UK Cheshire East and Kickstart Stop Smoking. Also part of the One You Cheshire East system are a range of community pharmacies, an NHS Trust, and a Community Interest Company which hold individual payment by results based contracts with the council, and a leisure charity which holds a block contract.

PEAKS & PLAINS and Age UK Cheshire East have the same values of promoting independence and personalised support, and have complementary skills. Age UK Cheshire East is ‘community facing’, providing the lifestyle support service – direct work with individuals of all ages, while PEAKS & PLAINS provides a bespoke IT service. The partnership has developed a model which has previously been deployed successfully in Cheshire in several wellbeing services.

PEAKS & PLAINS has developed a database capable of producing a range of data, including outcome measures by which to evaluate the service; workers from the provider plus organisations input into the database using iPads. Working with PHE, it has also developed the One You Cheshire East website, and in future there will be an online self-assessment tool.

Based on previous health trainer work, the lifestyle support service involves four support workers who undertake an ‘integrated threshold multi-service assessment’ to identify people who are eligible for services and support them to manage their health and wellbeing better. The model involves two levels of support. Level 1 includes information-giving and sign-posting – perhaps to other services in the One You Cheshire East system, or beyond such as debt advice; Level 2 involves individual lifestyle coaching, such as guided conversations and personal wellbeing plans.

During the mobilisation phase, public health has worked with the providers to shape the outcomes framework and undertake regular monitoring. Marketing is taking place to inform people about the new service. An action learning approach is being used in which providers and public health staff seek to make sure that the programme runs smoothly – for example, ensuring that referral pathways both into the service, between elements of the service, and out of the service are effective.

Learning and messages

From a VCSE perspective, longer term contracts provide the stable basis needed to properly introduce and grow a service. One You Cheshire East’s three year contracts, with a possible option of an additional two years, provides this stability – in contrast to one-year contracts which do not.

Cheshire East public health has operated a co-production approach, working with providers to develop outcomes and models. It is very beneficial when commissioners can work to promote a collaborative ethos in the VCSE sector where the need to win funding bids can create a tense, competitive environment. In relation to the One You Cheshire East service, work will need to be done to promote partnerships with organisations outside the programme so that cross-referrals can be seamless.

Basing the service around the national One You programme has brought the benefit of being able to build locally on a nationally recognised brand. It also gives access to a number of tools and resources. However, it is important that the national programme applies the least possible standard conditions so that local initiative is not stifled.

Contact Jane Branson, Public Health Commissioning Manager, Cheshire East Council Email: jane.branson@cheshireeast.gov.uk

Dominic Anderson, Deputy Chief Executive, Services and Development Age UK Cheshire East Email: dominic.anderson@ageukcheshireeast.org

Further information One You Cheshire East https://www.oneyoucheshireeast.org/about-us/

County Durham Wellbeing for Life – integrated health and wellbeing service with an academic evaluation

Wellbeing for Life (WBFL) is an integrated health and wellbeing service which provides individual, group, family and community-led interventions, targeted at the 30 per cent most deprived areas in the county, and at groups with specific health needs such as veterans and older people.

Wellbeing for Life model The service is asset-based, building on the strengths, skills and capacities of individuals and communities to promote independence and resilience. Instead of helping people with single-issue healthy lifestyle services it takes a whole-person and community approach. This involves offering a variety of individual, group and community-based activities.

The one-to-one health trainer intervention involves setting personal wellbeing plans in the range of health areas including diet, physical activity, stop smoking, mental wellbeing; it also provides signposting to support with the social determinants of health such as training, housing and benefits advice. The health improvement groups involve practical, physical and social activities, such as practical cooking, ‘walk and talk’ health walks and art classes.

In community health development, the service promotes a ‘community health champions volunteering programme’ which encourages local people to get involved in, and take control of, the health aspects of local communities. The health champions help to support the group interventions in order to develop social capital and enhance the sustainability of the groups. Local people, including those working in other organisations, have access to an extensive training programme delivered by WBFL staff.

WBFL was commissioned by Durham Public Health with a tender exercise in 2014. The tender was awarded to a consortium involving providers which brought different areas of expertise to the programme which went fully live in April 2015. The partners are:

- County Durham and Darlington NHS Foundation Trust Health Improvement Service (lead provider)
- Durham County Council, Culture and Sport
- Durham Community Action
- Leisureworks
- Pioneering Care Partnership.

Arrangements were put in place to help the consortium to work seamlessly and effectively together. Consortium members worked with public health to develop a memorandum of understanding (MoU) setting out roles, responsibilities, and relationships, and the MoU was linked into contract performance requirements. A WBFL manager was appointed to provide overall coordination, with three hub coordinators appointed to cover the three main delivery areas (North, East and South-West Durham). Communications, training and social marketing plans were devised and implemented.

**Independent evaluation**

Academic evaluation was built into the programme from the start. The evaluation, undertaken by a multidisciplinary team from Durham University, has been devised and overseen by a partnership of the university, public health commissioners and WBFL providers. It has two elements:

- evaluation of health and wellbeing outcomes for people using the service, including an estimate of the extent to which it provides value for money
- a qualitative study and process evaluation involving in-depth interviews and focus groups with WBFL service users, staff, volunteers and representatives of local partner organisations.

The final report is due in April 2017, and interim findings have been used by public health to shape the programme.

Monthly uptake of the programme has increased steadily and staff appear to be achieving success in terms of outreach work and one-to-one interventions. As of January 2017, the service had worked with 3,885 one-to-one clients, delivered 173 health improvement groups, trained 62 community health champions, provided 344 volunteer opportunities and supported 111 community groups in their roles around wellbeing.

Interim analyses of baseline and follow-up data gathered between June 2015 and July 2016 have highlighted significant improvements in self-rated health, mental wellbeing, BMI and various health-related behaviours amongst service users who completed the one-to-one WBFL intervention. BMI continued to reduce and physical activity levels continued to increase at the six-month follow-up stage, although these findings must be treated with caution due to the relatively small numbers involved. The final analyses include data gathered from all clients up to the end of January 2017. Learning and messages

The thinking behind designing the programme was that it should focus on behaviour change through encouraging healthier lifestyles rather than trying to directly tackle the wider social determinants of health, such as debt or housing, within the programme. As the service was rolled out, it was important not to stray too far from this focus, but changes are happening organically. For example, training for local people and community organisations has proved very effective and has led to around 20 people gaining employment.

During the commissioning process, the partners involved in the successful bid decided to form a consortium in order to meet all the skills and capacities required in the service specification. Although these were willing partners, the early months of the programme proved challenging, as they worked together for the first time and found cultural and practical differences such as different recruitment processes. There were also problems with performance, as some skilled staff had left existing services during the procurement period and had to be replaced.

The teething problems were overcome by the willingness of the organisations to resolve difficulties, and by public health both supporting the partners and using contract monitoring measures. Another important factor was the appointment of the WBFL coordinator who was able to facilitate joint work across the consortium.

Contact

Graeme Greig, Senior Public Health Specialist, Durham County Council Email: graeme.greig@durham.gov.uk

Dr Shelina Visram, Senior Lecturer in Public Policy and Health, Durham University Email: shelina.visram@durham.ac.uk

Further information

Wellbeing for Life http://www.wellbeingforlife.net/

Interim evaluation https://www.dur.ac.uk/public.health/projects/wellbeingforlife/

Living Well Sefton – integrated wellness service

New Realities The multi-award winning New Realities agreement was developed by Sefton Council and Sefton CVS in order to strengthen their working relationship. The agreement is based on the fact that resources are becoming scarce, so the borough needs to use all its assets and to create an enabling culture in which skills, expertise, solutions and costs are shared.

An important element of the agreement is ensuring that the council has a light touch with community initiatives that make life better for local people – moving from a gatekeeper, focused on potential blocks to action like health and safety or insurance, to an enabler that seeks to reduce barriers.

To make New Realities an embedded process, it is supported by a framework of mechanisms which include: regular meetings, a collaborative learning programme, a solutions framework to challenge and remove barriers, and honest case examples. For example, learning has been shared on initiatives such as park rejuvenation and community asset transfer – which went well – and community aspirations for living Christmas trees – which did not. Living Well Sefton The VCSE sector is a key strategic partner for Sefton Public Health. Prior to the transfer to the local authority, public health commissioned a range of wellbeing services that each tended to focus on their areas of specialist expertise, rather than considering the needs and strengths of individuals in a holistic way. The challenge was to shift to an integrated system based on principles of individual and community resilience and self-care.

One of the priorities was to help both statutory and voluntary providers shift from working in a competitive way to one in which they were willing to work collaboratively, sharing information and focusing on the needs of individuals and communities. To do this, public health built on New Realities and developed a co-production approach with Sefton CVS, working with 15 potential providers in task and finish groups, to develop a vision for an integrated service and to address some of the practical issues involved. One of these was around data sharing – it was decided to take the simplest approach of using anonymised data based on postcodes, setting up a central database which all providers could access.

The vision for the integrated service was that it would deliver the following measures:

- preventing unhealthy lifestyles and supporting the development of skills, capacity and support networks to help people live healthy lives
- support with a wide range of social determinants of health – isolation and loneliness, self-confidence, financial management skills and employment skills
- navigating the health and care system
- maximising community assets and developing opportunities for individual and community resilience
- whole family support.

A collaborative process was set up for an integrated wellness service, incorporating the previous health trainer framework, and with three main elements:

- Community resilience – includes measures such as volunteering, community navigators, rolling out MECC (Sefton CVS provides the training for MECC for all sectors), the mobile iVan service providing community health and wellbeing information and checks, and a range of community resources.
- Weight management service – programmes targeted at children.
- Stop smoking service – targeted at specific areas of need such as smoking in pregnancy and mental health.

Some elements of the service would be universal, while others would be targeted at particular groups or geographical areas of health inequalities. The contract would also make a saving of around £3 million over two years. Ten providers were successful – local authority leisure services, a social enterprise and eight VCSE organisations; the service started with a mobilisation phase in July 2016. Public health is now working with the providers to establish a joint vision and coordinated practice under a brand identity developed through consultation with providers and the public – Living Well Sefton. Several measures are in place to ensure that they work together.

- A coordinator funded by public health and employed by Sefton CVS has been appointed to support the providers to work together. This includes training in areas such as social marketing, customer services and MECC.
- A standard script approach is being used to deliver consistency of message and referrals across all providers.
- The bespoke IT system, which allows providers to record consistent information went live in January 2017. In time the system will allow public health to analyse data about patterns of referral and usage to improve the system.
- An outcomes system framework is being developed with measures such as ‘number of cross-referrals’; performance will be overseen by public health.

Learning and messages

New Realities is now on its way to becoming an established way of working, but has required all involved to look at things in a new way. For example, pressures on local authorities has meant they can be focused on budgets, income, risk avoidance and targets. While these are essential, it is also important to focus on the small things that matter to people. Messages about being proportionate about risk need to be repeated and reinforced. Practical things, for example helping people be clear about what is covered by public liability insurance, this can free up what citizens and volunteers can safely do. It is also important to analyse what works and what does not and be open about mistakes, all the while remembering the wider and most important aspect, which is that local people’s lives do improve and they do not merely become a number within a system.

The 2008 purchaser provider split in the NHS has brought an ongoing legacy of competition, rather than collaboration, between providers, and there can be a similar issue in the VCSE sector, with organisations focused on individual survival in a pressured environment. This can result in, for example, reluctance to refer individuals into other services. Supporting the VCSE sector and other providers to move towards a collaborative model involves both commissioners and providers changing how they relate to each other to a relationship based on trust, openness and understanding.

A particular issue was ensuring that the shared vision was owned by front-line staff, not just those who were involved in discussions about designing the model. Building trust at a time of reducing resources is particularly difficult, and the local authority had to show how the new model would result in a sustainable future. Overall, effective relationships take a long time to establish and can only be achieved by continuing joint work and dialogue.

Contact Anna Nygaard, Head of Public Health Delivery and Partnerships, Sefton Public Health Email: anna.nygaard@sefton.gov.uk

Andrea Watts, Head of Communities, Sefton Council Email: andrea.Watts@sefton.gov.uk

Karen Nolan, Living Well Sefton Programme Coordinator, Sefton CVS Email: karen.nolan@seftoncvs.org.uk Community-centred approaches

In recent years, national policies and initiatives, such as the Localism Act 2011, have encouraged local government to work more closely with local communities and the VCSE sector to increase their role in creating place-based wellbeing to complement public services. Since transferring to local authorities, public health has been both influenced by, and a driver of, community action.

The LGA describes community action as “activity that involves greater engagement of local citizens in the planning, design and delivery of local services”. Activity includes asset transfer to local community groups, better use of council-owned buildings to support community-led activities, community engagement in decision-making, co-designing services, community networks and community grants.(^{20})

NICE has produced a guideline(^{21}) on community engagement which describes a range of approaches to maximise the involvement of communities in local initiatives. These include needs assessment, community development, planning design, delivery and evaluation.

From a health and wellbeing perspective, community-centred approaches have been described in a guide(^{22}) by PHE and NHS England as ‘a family’ of approaches, such as community development, community hubs and volunteer health roles, all of which focus on mobilising community assets, tackling health inequalities and helping people to take more control over their health and their lives. In the guide, PHE considers a range of models for implementing the ‘family’, describes evidence and outcomes, and provides a framework for local commissioners.

PHE support

PHE supports the development of community-centered approaches as a core strategy to improve health and reduce the health gap in local communities. Based on the guide, it has been developing a communities programme which is focused on improving access to available knowledge and evidence, supporting learning and establishing an integrated approach across national partners. The family of community-centred approaches is recommended as an evidence based framework for local government and VCSE organisations to guide commissioning and practice.

PHE are building a bank of community-centred practice examples(^{23}), many of which involve partnership working between public health teams and local VCSE organisations. These examples offer a way for local areas to share learning about different practical models and what works well.

PHE centres are working to support the implementation of community-centred and asset-based approaches in local practice. PHE North East hold annual events bringing local government and VCSE sector providers together to consider the latest evidence and share best practice. PHE South East

______________________________________________________________________

(^{20}) LGA (2016), Community Action (web-based tools, resources and case studies) http://www.local.gov.uk/community-action

(^{21}) NICE, 2016, Community engagement: improving health and wellbeing and reducing health inequalities https://www.nice.org.uk/guidance/ng44

(^{22}) PHE, 2015, Public mental health leadership and workforce development framework https://www.gov.uk/government/publications/public-mental-health-leadership-and-workforce-development-framework

(^{23}) PHE good practice examples – click on ‘practice examples’ on home page http://phe.baileysolutions.co.uk/default.aspx?QL held a community-centred and asset-based workshop, co-produced with local authority colleagues, with the aim of sharing good practice and enabling collaboration. A steering group was established to develop and support delivery of an action plan based on the learning and needs identified in the event; this includes developing communities of practice.

Preparing the public health workforce to work with local community organisations is also important and PHE’s public mental health leadership and workforce development framework has competencies in empowering communities, improving mental wellbeing and addressing social factors. PHE are currently working with Health Education England to produce an e-learning module on community-centred approaches.

See ‘community-centred and integrated approaches’ in resource section for contacts.

Community development models

Some of the case studies in this report were using established community development models as a basis for their activity. These were found helpful in that they provided an evidence-based framework, with principles, tools and support which could be used to guide what councils and partners were aiming to achieve. They also helped areas to explore and understand concepts that are sometimes subtle and difficult to grasp. For example, to create ‘resilience’, organisations need to step back and facilitate people to identify solutions to their own problems rather than rushing in with solutions. Joint training for public health, the VCSE sector, communities and other stakeholders was seen as helpful for developing this shared understanding.

The areas that were basing their work on an established model were also clear that they were adapting this to meet local needs – using the elements that would fit with the local area rather than following an entire programme.

The models used by case studies include the following.

Asset based community development (ABCD)

One of the most established models, Asset based community development (ABCD) originates in the US Center for Civic Engagement in Northwestern University. ABCD is a set of theories and strategies based on the idea that communities have extensive assets, and that individuals, groups and organisations can mobilise and build on these to provide mutual support and improvements to lives and environments. Assets are wide-ranging and include relationships, skills, buildings and finance. ABCD is based on the principle that development should not be ‘done to’ communities by outside experts; instead facilitators should assist communities to participate in and lead development.

Leeds Public Health is using ABCD training for the providers of its community-based health living service, so that they are working to common community development approaches.

Connecting Communities (C2)

Founded in the UK by Hazel Stuteley OBE and based in Exeter University Medical School, Connecting Communities provides a seven-step asset-based approach to building partnerships in communities based on evidence and research. It focuses on reconnecting local residents and frontline services so they can jointly improve local conditions in disadvantaged areas. It emphasises citizens being at the centre of problem solving and decision-making in their areas, and high levels of community self-organisation.

24 PHE (2015) Public mental health leadership and workforce development framework https://www.gov.uk/government/publications/public-mental-health-leadership-and-workforce-development-framework

25 http://www.abcdinstitute.org/index.html

26 https://www.collegeofmedicine.org.uk/innovations-projects/connecting-communities/ One of the priorities in Tower Hamlets’ Health and Wellbeing Strategy is ‘communities driving change’ which includes a new ‘health creation’ programme to empower local people to take control over their lives and environments. The model underpinning health creation is Connecting Communities.

**Locality – community anchors**

Locality, a national network of community-led organisations, promotes a theory of change which emphasises the concept of ‘community anchors’ – community hubs which provide stability, flexibility and support in response to local needs and connect people into activities and services as well as strengthening local networks. The model stresses long-term community ownership of assets, supporting enterprise and service delivery in local neighbourhoods.

In Wakefield, community anchors are an important element in work to increase prevention as an alternative to hospital and care services as part of the Connecting Care Wakefield integration pioneer. They are also central to its new Social Wellbeing Service.

**Local Area Coordination**

Although not a model adopted by any of the case studies, Local Area Coordination is another approach which has been or is currently used in several areas. Local Area Coordination covers all groups of people with social care needs; it works by coordinators being embedded in communities so they can form ‘real relationships’ and identify local potentials and solutions. Coordinators have a wide-ranging role which could involve supporting people to make life changes, representing their views, helping them to navigate the health and care system, developing support networks, being a catalyst for service reform and building community capacity. A recent report on Local Area Coordination in Derby City and Thurrock by the Centre for Welfare Reform shows results in measures such as reduced dependency on expensive statutory services, reduced social isolation and better integrated services.

**Other asset focused approaches**

**Health in all policies**

Health in all policies (HiAP) is becoming a cornerstone approach, as public health seeks to influence all its partners within and outside local government to shape their activity in a way which helps improve people’s health. In its recent report on HiAP, the LGA indicates:

Many councils are now looking to adopt HiAP more formally and comprehensively. During the period of settling in local government, public health instigated several of the approaches included in HiAP through their asset-based work with communities.

MECC has been extended to the VCSE sector in many areas, while others have plans to do so soon.

The community resilience strand of Living Well Sefton includes measures such as volunteering, community navigators and rolling out MECC. Sefton CVS provides MECC training for all sectors.

Peer volunteering is a goal of many VCSE projects which seek to increase the number of people who volunteer to help people of similar age or in similar situations, and also to assist people who have received a service to themselves become volunteers. Being a volunteer has been found to bring health and

______________________________________________________________________

27 [http://locality.org.uk/about/](http://locality.org.uk/about/)

28 Locality, 2015, Theory of Change: supporting communities to build successful neighbourhoods [http://locality.org.uk/wp-content/uploads/Theory-of-Change.pdf](http://locality.org.uk/wp-content/uploads/Theory-of-Change.pdf)

29 [http://lacnetwork.org/](http://lacnetwork.org/)

30 Centre for Welfare Reform (2016), People, Places, Possibilities: progress on local area coordination in England and Wales [http://www.centreforwelfarereform.org/library/type/pdfs/people-places-possibilities.html](http://www.centreforwelfarereform.org/library/type/pdfs/people-places-possibilities.html)

31 LGA (2016), Health in all policies: a manual for local government [http://www.local.gov.uk/documents/10180/7632544/1.4+Health+in+ALL+Policies_WEB.PDF/b21cf56f-403e-45c4-8a29-2c96df48acdb](http://www.local.gov.uk/documents/10180/7632544/1.4+Health+in+ALL+Policies_WEB.PDF/b21cf56f-403e-45c4-8a29-2c96df48acdb) wellbeing benefits. For example, a systematic review commissioned by Volunteering England found a range of improvements such as decreased depression, reduced social isolation, better family relationships, increased self-esteem and healthier lifestyles.

Camarados volunteers in Blackpool are “someone between a stranger and a friend” who will share the journey of someone with wellbeing needs for a period of time. There is an emphasis on “fun, friendship and doing things we enjoy – services don’t do things like that very often but people do”.

Lifelines in Brighton is a volunteer-led project for people aged 50 and over based on recruiting, training and supporting older volunteers to set up activities that they are interested in and which will be of interest to others. During the last three years it has recruited 149 volunteers of whom nearly three-quarters said that they felt less isolated and had more self-confidence.

Localism In their community leadership role, councillors are working at ward and neighbourhood level to support local communities – individuals and organisations – to promote health and wellbeing. The democratically accountable role of the councillor is uniquely placed to understand the needs of communities, and take a joined up approach to meeting them. The role of councillors should be integrated with any framework for community-centred approaches in local neighbourhoods.

Sometimes localism approaches involve ‘small grants’ schemes to VCSE organisations, generally allocated through local partnerships.

In Wakefield, the Social Wellbeing Service will involve the VCSE lead provider, Nova, managing a Social Wellbeing Grants process with community anchors to develop interventions to reduce social isolation and increase independence.

Explaining difficult concepts Community action and the ‘family’ of community-centred public health approaches often involve subtle concepts like ‘resilience’ that can be difficult for people to grasp and translate into practical action. (See PHE and NHS England and IDeA, for helpful explanations.) Public health teams were aware of the need to adopt clear language and repeat key messages in the same format to both internal and external stakeholders. It was also important to reinforce understanding directly with front-line staff who would not have been involved in planning activity – rather than expecting difficult concepts to be cascaded through normal management structures. Another positive way of generating understanding was to use case examples, which grounded abstract concepts in behaviours.

Sefton’s New Realities initiative shares learning through a framework of mechanisms which include: regular meetings, a collaborative learning programme, a solutions framework to challenge and remove barriers, and honest case examples. For example, learning has been shared on initiatives such as park rejuvenation and community asset transfer – which went well – and community aspirations for living Christmas trees – which did not.

Wakefield – VCSE sector is a key partner in integration pioneer and care model vanguards Wakefield Public Health believes that the VCSE sector has a big contribution to make to improving health and wellbeing in the district, and works closely with the sector to develop its role.

32 Volunteering England (2008), Volunteering and health: what impact does it really have? http://www.ivr.org.uk/ivr-news/133-volunteering-adn-health-what-impact-does-it-really-have

33 PHE and NHS England (2015), A guide to community-centred approaches for health and wellbeing https://www.gov.uk/government/publications/health-and-wellbeing-a-guide-to-community-centred-approaches

34 IDeA (2010), A glass half-full: how an asset approach can improve community health and wellbeing http://www.local.gov.uk/c/document_library/get_file?uuid=b034d2e-7d61-4fac-b37e-f39dc3e2f1f2&groupId=10180 Nova is the infrastructure agency for voluntary and community organisations, providing a range of services including the Wakefield Assembly, contract readiness and coordination for organisations wanting to provide services for the statutory sector, and helping with the recruitment and retention of volunteers. Nova employs a health and social care advisor who works to ensure that the sector’s views are included in strategic planning and service delivery.

Nova and public health work together within the context of the integration pioneer programme – Connecting Care Wakefield – which includes two vanguard schemes. For example, Nova has been active in developing a model for a VCSE contribution to social prescribing or the multi-speciality community provider vanguard.

**Developing community anchors**

Community anchors are neighbourhood organisations with multi-purpose facilities used by local communities. Anchors are a driving force for community renewal, with an ethos of listening and responding to the changing needs and priorities of local people, and seeking to promote a culture of self-reliance.

Public health has funded the development of community anchors as part of the Connecting Care programme, which aims to shift activity and resources from high-level health and care to prevention. Services provided by anchors includes exercise classes, community cafés, childcare facilities, and adult learning and skills development. Anchors are now being supported to extend their work in areas such as greater use of volunteers, attracting more investment, being an umbrella for smaller community groups, and better links with GPs on social prescribing.

Wakefield has just awarded a Social Wellbeing Service based on the Five Ways to Wellbeing model to a partnership of Nova and South West Yorkshire Foundation Trust (SWYFT). Nova is the lead partner, placing staff in local community anchors and sub-contracting to SWYFT. As one element of this, Nova has been commissioned to manage a Social Wellbeing Grants process with the anchors and the wider VCSE to develop interventions to reduce social isolation and increase independence in response to priorities identified by the Social Wellbeing Service.

**Care home vanguard**

One of Wakefield’s two vanguards aims to improve the quality of life for older people in supported housing and care homes by improving the input from GPs and care workers, and helping them to access community activities. Nova is piloting a scheme in which two community anchors have provided volunteers to deliver activities such as chair based exercise, community gardening and befriending individuals. It is now looking to expand this to other homes and community anchors, and other VCSE organisations.

**Joint leadership programme**

One of the gaps identified in the training needs of the VCSE sector was leadership, to enable people to progress in their careers and to bring leadership skills to the sector as a whole. At the same time, it was recognised that there was limited understanding across the council about how the sector operated and what it could achieve. A joint leadership programme in which VCSE and council managers train together has been established. All 11 VCSE sector participants have a mentor who is a senior leader in the statutory sector – including NHS trust and CCG chief executives and council directors of adult social care and finance – and participants from the statutory sector are mentored by VCSE chief executives; participants also receive professional coaching and educational input. The course will allow current and future leaders to network and will raise the profile of the VCSE sector.

**Learning and messages**

It is important for commissioners to strike the right balance in their relationship with the VCSE sector. Organisations receiving taxpayer’s money must be accountable for how they use the funding and the outcomes they achieve. However, it is not helpful if commissioners are overly controlling – one of the key advantages of the sector is that it should be able to be responsive to local needs. Being clear, open and transparent about procurement is essential.

There are opportunities to be creative in relationships with the sector – such as providing long leases on buildings which allows organisations to raise a mortgage. More should be done strategically to help the sector unlock other investment.

Continuing to break down barriers and build mutual understanding is very important.

**Contact** Anna Middlemiss, Wakefield Council Deputy Director of Public Health Email: amiddlemiss@wakefield.gov.uk

Jan Firth, Nova Adviser (Health and Social Care), Nova Email: jan.firth@nova-wd.org.uk

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**Holiday Kitchen – a collaboration to improve health outcomes for disadvantaged children**

“If the investment in Holiday Kitchen is considered in relation to the value of the outcomes it achieves over the short and medium term, a compelling case emerges for an ‘invest to save’ investment in this type of programme by prevention and early help teams.”

**Birmingham City University evaluation**

Holiday Kitchen is a programme offering opportunities for play, learning and healthy food to low-income and vulnerable families with pre or primary school children during school holidays, particularly the stressful summer break when free meals and support from schools are not available.

The initiative stemmed from a community consultation in a deprived neighbourhood in Birmingham conducted by Ashrammosely, a housing association which is part of the Accord Group a social housing provider in the West Midlands. Food poverty and lack of summer activities topped the list of needs identified, so with the help of a Children in Need grant Ashrammoseley ran the first Holiday Kitchen in 2013.

Following the success of the initial programme, this was expanded, and the Accord Group now provides training for areas across the West Midlands and in Greater Manchester and Lincolnshire.

A key feature of Holiday Kitchen is that PHE West Midlands provides expert advice to the programme, and is supporting the development of the evidence base, working with Birmingham City University. The initiative already has a strong research base which will be of interest to other areas. The model Each Holiday Kitchen programme operates on eight days throughout the long summer break; this is divided into two half days a week so that if there is a crisis at home, participants are only a few days from the next session. Activities include ‘forest school’ – exploring the countryside, ‘field to fork’ – growing vegetables, ‘park challenge’ – physical activity, ‘make and taste’ – cooking and trying new foods, story-based drama, ‘money fun’ – money management and budget shopping, and a final celebration. Parents or carers are expected to be involved, spending time with their children. Each half-day includes a community-cooked healthy meal. Families are referred to the programme from schools, social workers, children’s centres and the like; self-referrals may also be accepted.

In summer 2016 Birmingham Council delivered 22 programmes across the city, particularly in venues such as children’s centres and domestic violence refuges. Six thousand meals were delivered to families, heavily supported by local authority catering and Fareshare, the charity tackling food waste and poverty.

Evaluation Holiday Kitchen has been evaluated by Birmingham City University over successive years since 2014. The 2015 evaluation of the programme in Sandwell was sponsored by PHE West Midlands and focused on two measures:

• whether involvement in the programme resulted in sustained short/medium term outcomes for individuals • the social value and value for money of outcomes for individuals and statutory agencies.

It found that over time there appears to be a continuum of programme impact for some participants who have achieved medium term applied knowledge, and, in some cases, sustained behaviour change in relation to one or more of the programme’s key objectives:

• improved nutrition • stronger relationships • engagement in positive learning activities.

Financial analysis indicates that the cost of the programme of less than £400 per family compares favourably with the cost of a group parenting course – £580. Also, based on financial proxies for a range of medium term outcomes, the evaluation concludes that there is a ‘compelling case’ for an ‘invest to save investment in this type of programme’.

Contact Caroline Wolhuter, Head of Social Inclusion, Ashrammoseley Email: caroline.wolhuter@ashrammoseleyha.org.uk

Karen Saunders, Health and Wellbeing Programme Lead/Public Health Specialist, PHE West Midlands Email: karen.saunders@phe.gov.uk

Further information Holiday Kitchen evaluations https://accordgroup.org.uk/about/projects-and-partnerships

Holiday Kitchen arts and crafts Support for marginalised people in Blackpool

In Blackpool, national charity Camerados has been commissioned to run the Living Room – a safe and approachable space for individuals who are lonely, socially isolated and having a tough time. The Living Room is a place where services in the town can send or take people who are not involved in services but clearly in need of some support in a non-clinical setting. It is also open to the general public, so anyone needing to spend time in a safe and supportive place can drop in. Similar to the Samaritans, but in a Living Room format, the project does not present as an intervention, although people are available to help others experiencing life difficulties.

Camarados operate with an ethos which is somewhat different from most other services. A camerado is ‘someone between a stranger and a friend’ who will share the journey of someone with wellbeing needs for a period of time. There is an emphasis on ‘fun, friendship and doing things we enjoy – services don’t do things like that very often but people do.’ Camerados also indicates ‘we’re cutting through the rubbish and getting people what they want and need.’

The Living Room was set up to feel more like a high street coffee shop than a community centre. It started life as a four-week pop up café, and its success meant that it has continued to operate ever since. Initially the project was run by volunteers but as it developed funding has been provided to further develop and test the model, and to have the café operating at different times of the day and night.

The café has been set up in Blackpool Central Library as an accessible community venue well used by the public. As well as providing support for people in distress, it is a community facility that people can access on a regular basis, with a range of group arts, craft and social activities.

Contact Nicky Dennison Senior Public Health Practitioner, Blackpool Council Email: nicky.dennison@blackpool.gov.uk

Further information Camerados https://www.camerados.org/ Public health in partnership with the VCSE sector: suggestions for good practice

Relationships The case studies in this report show great mutual regard, trust and understanding between public health and the VCSE sector – a relationship of equals which form the basis of all subsequent work. Relationships develop over time but there are many ways of accelerating this, for example:

• organise shared events to enable public health and the VCSE sector to discuss: ◦ how the local VCSE sector operates, for example, the work of infrastructure organisations and sector forums ◦ the contribution that the VCSE sector can make to health and wellbeing through expertise, contacts and resources ◦ the range and potential of VCSE organisations in the local area ◦ how public health operates, its work and priorities. • appoint a public health lead to be the link with the sector • establish strong relationships with, and support, the VCSE infrastructure organisation • identify opportunities for shared training with the VCSE sector • consider temporary placements in each other’s organisations • work with the VCSE to establish a health and wellbeing forum or similar mechanism.

Engagement Engagement of the VCSE sector in strategic planning seems variable across the country. Public health may wish to work with the VCSE sector and other partners to ensure that they are fully involved in all aspects. For instance:

• review whether there are robust mechanisms for the VCSE representatives on the HWB to feed in the views of those they represent and feed back to them • if the VCSE sector is not represented on the HWB, see if this can be reviewed and check what other measures are in place • work with the VCSE infrastructure organisation to ensure that the whole sector is fully involved in JSNAs • work with the infrastructure organisation to consider whether a specific VCSE role to drive developments in health and wellbeing would be beneficial • ensure that public health teams are familiar with the local Compact, and this is amended if necessary to respond to current priorities in health, care and wellbeing • with the VCSE sector, consider how it can be involved in regional developments such as STPs and devolution.

Joined-up approach across public health, the council and CCG As well as public health, other council departments and CCGs also engage with, and commission, the VCSE sector. Joining up this work will bring economies of scale and also avoid risks involved in poor coordination.

• Establish a mechanism across the council, the CCG and the VCSE to provide oversight of the work done with the VCSE sector to avoid duplication, address gaps and tackle problems. For example, when commissioning or de-commissioning services, or where a new development like social prescribing has an impact across the sector. • Work on activity such as community-centred approaches through joint teams wherever possible.

**Commissioning and procurement** Commissioning is increasingly important in public health, and greater understanding of all its elements may be helpful to public health teams. A key message from case studies and recent reports is that a culture of collaboration rather than competition should be encouraged, for example:

• Set up training in procurement so that relevant public health staff understand the process, including when competitive tendering is required, when it is the best option, and when it would not be helpful.

• Establish regular contact with council commissioning and contracting teams so that they understand the commissioning needs of public health.

• When re-commissioning services, establish a comprehensive review and consultation process. This should include ensuring that existing providers feel valued and included, as well as involving new potential providers.

• Ensure that commissioning and procurement processes are transparent and explained to the sector.

• With the VCSE sector, develop approaches that encourage collaboration. This might include forums in which ideas, problems, solutions and resources can be shared, or supporting the development of consortia and partnerships.

**Market development for a sustainable VCSE sector** Public health needs to support the VCSE sector so that it includes a range of thriving organisations with different skills and capacities for delivering health and wellbeing outcomes, tackling health inequalities and addressing the social determinants of health. Working with the VCSE infrastructure organisation and the sector, measures to achieve this include:

• wherever possible use contracts of at least three years’ duration

• establish a mechanism in which the VCSE sector and public health can look at how they can use all their resources and assets to the best advantage

• encourage and support VCSE organisations to apply for external funding for programmes that improve health

• support VCSE organisations, particularly small community groups, to increase their ability to evaluate and demonstrate the value of their work

• understand the potential of the Social Value Act for contributing to public health outcomes and develop a strategy to increase its use in local commissioning.

**Developing integrated services** Experience from case studies show that service models involving multiple providers delivering an integrated service together for the first time involves careful oversight and support until working practices are established. Methods of achieving effective integration include:

• a mobilisation period at the start of the contract to establish procedures and iron out problems

• a coordinator to bring partners together, address difficulties and, where relevant, help organise:

• a shared IT system

• shared outcomes and a unified performance monitoring system

• shared processes such as assessment and referrals

• ensure the model is written up, is clear to all stakeholders, and is evaluated: consider whether an independent evaluation would be helpful.

**Developing community-centred approaches** Experience from case studies is that developing a local community-centred model as the basis for local work is helpful. There is a growing body of information and support on this from PHE including its communities programme. This is a large area that can only be touched on here, but some of the good practice from case studies includes: • Involve the VCSE sector in developing a local model including developing a shared understanding of concepts like ‘resilience’ and ‘self-care’. Use practical examples to develop understanding.

• Joint training in community-centred work for the public health workforce and the VCSE sector.

• Integrate a range of asset-based activities within the model, such as health in all policies, MECC and peer volunteering.

• Integrate the model with other approaches to localism, including the work of ward councillors.

• Establish a written framework for the model so it is clear to all and has clear outcomes.

• Establish a mechanism for evaluation, including considering independent evaluation. References and resources

References Centre for Welfare Reform, 2016, People, Places, Possibilities: progress on local area coordination in England and Wales. http://www.centreforwelfarereform.org/library/type/pdfs/people-places-possibilities.html

DH, PHE, NHS England, 2016, Review of partnerships and investment in voluntary community and social enterprise organisations in the health and care sector – final report 2016 (‘The National VCSE Review’). https://VCSEreview.org.uk/

IDeA, 2010, A glass half-full: how an asset approach can improve community health and wellbeing. http://www.local.gov.uk/c/document_library/get_file?uuid=bf034d2e-7d61-4fac-b37e-f39dc3e2f1f2&groupId=10180

LGA, 2016, Care Act Stocktake 6. http://www.local.gov.uk/care-support-reform/-/journal_content/56/10180/6341378/ARTICLE

LGA, 2016, Community Action (web-based tools, resources and case studies). http://www.local.gov.uk/community-action

LGA, 2016A, Health in all policies: a manual for local government. http://www.local.gov.uk/documents/10180/7632544/1.4+Health+in+ALL+Policies_WEB.PDF/b21cf56f-403e-45c4-8a29-2c96df48acdb

LGA, 2016, Commissioning for better health outcomes. http://www.local.gov.uk/web/guest/publications/-/journal_content/56/10180/7954763/PUBLICATION

LGA, February 2017, Working with faith groups to promote health and wellbeing. http://www.local.gov.uk/web/guest/publications/-/journal_content/56/10180/8220302/PUBLICATION

LGA, April 2017, Public transition four years on: maximising the use of limited resources. http://www.local.gov.uk

Locality, 2015, Theory of Change: supporting communities to build successful neighbourhoods. http://locality.org.uk/wp-content/uploads/Theory-of-Change.pdf

NAVCA, 2016, In sickness and in health. https://www.navca.org.uk/news/264-demonstrating-impact-essential-for-smaller-charities

NAVCA, 2016, Health and local infrastructure. https://www.navca.org.uk/resources/134-health-and-local-infrastructure

NICE, 2016, Community engagement: improving health and wellbeing and reducing health inequalities. https://www.nice.org.uk/guidance/ng44

NPC, 2016, Untapped potential: bringing the voluntary sector’s strengths to health and care transformation. https://richmondgroupofcharities.org.uk/sites/default/files/aw_ncp_report\_-_untapped_potential_-\_single_pages.pdf

PHE, 2015, Public mental health leadership and workforce development framework. https://www.gov.uk/government/publications/public-mental-health-leadership-and-workforce-development-framework

PHE and NHS England, 2015, A guide to community-centred approaches for health and wellbeing.

https://www.gov.uk/government/publications/health-and-wellbeing-a-guide-to-community-centred-approaches

PHE and UCLIHE, 2015, Using the Social Value Act to reduce health inequalities in England through action on the social determinants of health.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/460713/1a_Social_Value_Act-Full.pdf

SEUK, 2016, Procuring for good: how the social value act is being used by local authorities.

http://www.socialenterprise.org.uk/uploads/files/2016/05/procuringforgood1.pdf

TLAP, 2015, Top Tips: commissioning for market diversity.

http://www.thinklocalactpersonal.org.uk/Latest/Top-Tips-Commissioning-for-Market-Diversity/

Volunteering England, 2008, Volunteering and health: what impact does it really have?

http://www.ivr.org.uk/ivr-news/133-volunteering-adn-health-what-impact-does-it-really-have

Resources ACEVO, the network for charity and social enterprise leaders.

https://www.acevo.org.uk/

Asset based community development ABCD.

http://www.abcdinstitute.org/index.html

DH, VCSE Alliance.

https://www.gov.uk/government/publications/VCSE-health-and-wellbeing-alliance-application-form

Contact: Professor Jane South, National Advisor, Communities, PHE. Email: jane.south@phe.gov.uk

Community-centred and integrated approaches: contacts

PHE national contact: Professor Jane South, National Advisor, Communities. (PHE Communities Programme) Email: jane.south@phe.gov.uk

PHE good practice examples – click on ‘practice examples’ on home page.

http://phe.baileysolutions.co.uk/default.aspx?QL

Contact: Wendy Marsh, Senior Knowledge and Evidence Manager Email: wendy.marsh@phe.gov.uk

PHE NE contact: Claire Sullivan, Deputy Director Health and Wellbeing. Email: Claire.sullivan@phe.gov.uk

PHE SE contact: Terry Blair-Stevens, Public Health Consultant Health and Wellbeing. Email: terry.blair-stevens@phe.gov.uk

NE integrated health and wellbeing cross-site evaluation team.

Michelle Mancini, Public Health Officer, PHE. Email: Michelle.Mancini@phe.gov.uk

Shelina Visram, Senior Lecturer in Public Policy and Health, Durham University. Email: shelina.visram@durham.ac.uk

Professor Rosemary Rushmer, Professor in Knowledge Exchange and Public Health. Email: r.rushmer@tees.ac.uk

Mandy Cheetham, Fuse Postgraduate Research Associate, Teeside University. Email: mandy.cheetham@gateshead.gov.uk

Compact. http://www.compactvoice.org.uk/ C2 Connecting Communities.

https://www.collegeofmedicine.org.uk/innovations-projects/connecting-communities/

http://medicine.exeter.ac.uk/research/healthresearch/childhealth/healthcomplexityandchildhealthgroup/connectingcommunities/

LGA, 2012, Community leadership councillor workbooks.

http://www.local.gov.uk/councillor-development/-/journal_content/56/10180/6175947/ARTICLE

LGA and partners, 2015, Commissioning for better outcomes: a route map.

http://www.local.gov.uk/documents/10180/5756320/Commissioning+for+Better+Outcomes+A+route+map/8f18c36f-805c-4d5e-b1f5-d3755394cfab

LGA, May 2016, Just what the doctor ordered: a social prescribing guide for local authorities.

http://www.local.gov.uk/documents/10180/7632544/L16-108+Just+what+the+doctor+ordered++social+prescribing+-+a+guide+to+local+authorities/f68612fc-0f86-4d25-aa23-56f4af33671d

Local Area Coordination

http://lacnetwork.org/

Locality – the national network of “ambitious and enterprising” community-led organisations.

http://locality.org.uk/about/

National voices – the coalition of health and care charities in England.

http://www.nationalvoices.org.uk/

NAVCA – the national membership organisation for local infrastructure, with a network of local charities and community groups.

https://www.navca.org.uk/

NCVO – champions the sector by connecting, representing and supporting voluntary organisations.

https://www.ncvo.org.uk/

NPC – Independent think tank and consultancy for the charity sector.

http://www.thinknpc.org/

Social Value Act Hub.

http://www.socialvaluehub.org.uk/resources

Think Local Act Personal (TLAP) – the national partnership for transforming health and care through personalisation and community-based support.

http://www.thinklocalactpersonal.org.uk/

TLAP, 2015, Engaging and empowering communities: our shared commitment and call to action.

http://www.thinklocalactpersonal.org.uk/Latest/Engaging-and-Empowering-Communities-a-shared-commitment-and-call-to-action/

Volunteering Matters – the national organisation for volunteering and social action.

https://volunteeringmatters.org.uk/